Mar 29, 2016
On April 7, the Medicare Payment Advisory Council (MedPAC) will vote on a proposed change to Medicare Part D that could substantially impact low-income people with mental illnesses. MedPAC is an independent Congressional agency that advises Congress on Medicare programs. The proposal they are considering would lower cost-sharing requirements for generic medications but would significantly increase cost-sharing requirements for brand medications. Many people with mental illness, particularly those with other chronic health conditions, need access to brand name medications to control symptoms, minimize side-effects and prevent drug interactions.
In addition, MedPAC’s proposal would eliminate “protected status” for antidepressants, removing the requirement for Medicare plans to cover almost all drugs in this class. This could limit access to these medications. This plan targets only low-income beneficiaries who live at or below 135% of the federal poverty level, which is around $16,000 per year for a single adult. This proposal sets a dangerous example by targeting low-income individuals to achieve cost savings.
Below is a letter that NAMI joined with over 250 organizations in urging MedPAC not to raise cost sharing on low-income Medicare beneficiaries.
March 24, 2016
Francis J. Crosson, M.D.
Medicare Payment Advisory Commission
425 I Street, NW, Suite 701
Washington, D.C. 20001
Dear Chairman Crosson,
We are writing to urge you to not issue recommendations to Congress in support of increasing cost sharing, particularly co-pays, for brand medicines used by Low-Income Subsidy (LIS) beneficiaries in the Medicare Part D program. We also caution you in issuing recommendations that would widen the gap between generic and brand cost sharing for this population as this might trigger prescribing changes that could negatively impact care for vulnerable populations.
Recently, MedPAC and others have considered several proposals to change cost sharing for LIS populations. Specifically, MedPAC has explored increasing brand co-payments, or eliminating generic copayments as a way to encourage additional take up of generics for the LIS population. MedPAC has argued LIS enrollees tend to utilize fewer generics than their non-subsidy eligible counterparts. However, generic utilization is already high among all Part D beneficiaries and has increased every year since the program began. Further, increased cost sharing for vulnerable beneficiaries could reduce adherence, increase spending on other health care services, and worsen health outcomes.
Generic Utilization Already High in Both LIS and Non-LIS Populations
MedPAC’s own data show high generic utilization rates for LIS and non-LIS populations, with generic use steadily increasing for both groups. In 2013, 81 percent of LIS beneficiary prescriptions were filled with generics, versus 85 percent of non-LIS prescriptions, with the generic use rate growing slightly faster for LIS beneficiaries from 2012 to 2013. An analysis of Medicare Part D claims data by the University of Maryland found almost no difference in generic utilization rate between non-LIS Part D enrollees and partial benefit LIS enrollees with diabetes. Relative to non-low income beneficiaries, LIS beneficiaries are in poorer health and often have multiple conditions or diseases and are more likely to be disabled. These differences in health status can help explain differences in generic utilization between LIS and non-LIS beneficiaries.
Higher Cost Sharing for Branded Products Could Reduce Adherence, Increase Spending on Other Health Care Services in Medicare/Medicaid
MedPAC also notes that this proposal may cause LIS enrollees to pay higher cost sharing for brand name drugs or they might not be as adherent to their prescribed treatment. We are very concerned that reduced adherence for vulnerable LIS beneficiaries would compromise patient outcomes, and raise overall Medicare costs. As already noted, LIS beneficiaries often have multiple chronic conditions, higher rates of disabilities, and more functional or cognitive impairments than non-LIS enrollees. As a result, any changes in medication can be particularly harmful for these beneficiaries.
About half of all LIS beneficiaries qualify for Medicare before age 65 due to a disability, compared to 15 percent of non-LIS beneficiaries. Overall, LIS beneficiaries tend to be in worse health than other Medicare beneficiaries, and therefore may need multiple brand medicines to treat their chronic and often complex conditions. In fact, MedPAC has noted due to the complexity of their conditions, LIS beneficiaries tend to fill more prescription than other beneficiaries, on average. This means that higher relative copays would disproportionately penalize this population.
We are also concerned that a decline in medication adherence will only lead to poorer health outcomes, which in turn will cost the Medicare and Medicaid programs even more in avoidable hospitalizations and other unnecessary medical care. We should be encouraging these patients to take the medications their doctors prescribe rather than creating barriers that could lead them to skip doses or switch medicines, which could disrupt their treatment plans.
As part of your deliberations, we encourage you to instead look at improving the appeals process for denied coverage of specific drugs. Recent findings of the CMS’ audits of plan sponsors revealed ongoing challenges related to coverage determinations, appeals and grievances (CDAG) as well as formulary and benefits administration. CDAG violations continue to be a key driver of CMS penalties and sanctions. There are several reforms MedPAC could consider, including improving plain language denial notices to beneficiaries, improved data collection, and up front coverage determinations as a means to enhance affordability and medication adherence for the Part D LIS population.
We appreciate your attention to this issue and look forward to working with you on these important issues. We are happy to be a resource to MedPAC as you continue your deliberations on these issues and can meet with you and the Commission staff at your convenience.
Sincerely,
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National Organizations |
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AIDS United |
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Alliance for the Adoption of Innovations in Medicine (Aimed Alliance) |
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American Association on Health and Disability |
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American Autoimmune Related Diseases Association |
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American Behcet's Disease Association |
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American Liver Foundation |
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American Psychiatric Association |
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American Psychological Association |
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Asian & Pacific Islander American Health Forum |
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Association for Ambulatory Behavioral Healthcare |
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Caregiver Action Network |
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Center for Healthcare Innovation |
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Children and Adults with Attention-Deficit Hyperactivity Disorder (CHADD) |
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Christopher & Dana Reeve Foundation |
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Community Access National Network (CANN) |
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Easter Seals |
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Global Colon Cancer Association |
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Global Healthy Living Foundation |
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HealthHIV |
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Lakeshore Foundation |
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Lupus and Allied Diseases Association |
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Lupus Foundation of America |
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Malecare Cancer Support |
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Medical Partnership 4 MS (MP4MS) |
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Men's Health Network |
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Multiple Sclerosis Foundation National Alliance on Mental Illness (NAMI) |
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NAACP |
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National Asian Pacific Center on Aging |
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National Association of Nutrition and Aging Services Programs (NANASP) |
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National Association of State Head Injury Administrators |
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National Association of States United for Aging and Disabilities |
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National Black Nurses Association |
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National Council for Behavioral Health |
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National Council of Asian Pacific Islander Physicians |
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National Disability Rights Network |
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National Down Syndrome Society |
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National Grange |
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National Hispanic Council on Aging |
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National LGBT Cancer Project |
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National Minority AIDS Council (NMAC) |
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National Multiple Sclerosis Society |
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National Osteoporosis Foundation |
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National Patient Advocacy Foundation National Stroke Association |
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National Viral Hepatitis Roundtable |
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No Health without Mental Health (NHMH) |
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OWL-The Voice of Women 40+ |
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RetireSafe |
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Salud USA |
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Schizophrenia and Related Disorders Alliance of America |
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Suicide Awareness Voices of Education |
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The AIDS Institute |
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The American Orthopsychiatric Association |
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The Arc of the United States |
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The Veterans Health Council United Spinal Association |
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US Pain Foundation Inc |
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Vasculitis Foundation |
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Vietnam Veterans of America |
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Women's Institute for a Secure Retirement State & Local Organizations |
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1 in 9: The Long Island Breast Cancer Action Coalition |
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ADAP Advocacy Association (aaa+) |
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Advocates for Responsible Care( ARxC) |
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State and Local Organizations |
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AIDS Alabama |
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AIDS Resource Center Ohio |
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AIDS Response Seacoast |
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Alzheimer's & Dementia Resource Center |
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Alzheimer's and Dementia Alliance of Wisconsin |
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Applied Pharmacy Solutions; Touro University California College of Pharmacy |
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Asthma & Allergy Foundation of America, New England Chapter |
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Autoimmune Advocacy Alliance |
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Behavioral Health & Wellness |
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Benjamin Rose Insititue on Aging |
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Bio Nebraska Life Sciences Assocation |
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BioForward |
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Bioscience Association of WV |
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Brain Injury Association of Nebraska |
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California Chronic Care Coalition |
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California Life Sciences Association (CLSA) |
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California NAACP |
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California Senior Advocates League |
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Capital Area Agency on Aging |
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Caring Families Coalition |
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Cascade AIDS Project |
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Central Florida Behavioral Health Network |
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Charleston Parkinson's Support Group |
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CNY HIV Care Network |
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Combined Health Agencies |
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Community Behavioral Healthcare Assoc of Illinois |
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Community Health Action Network (CHAN) |
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Community Health Charities of Nebraska |
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Community Liver Alliance |
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Dia de la Mujer Latina |
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East Georgia Cancer Coalition Inc. |
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Easter Seals Central and Southeast Ohio |
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Easter Seals Massachusetts |
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Easter Seals North Georgia, Inc. |
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Eldercare Advocacy of Florida |
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Empower Missouri |
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Epilepsy Foundation |
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Epilepsy Foundation Heart of Wisconsin |
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Epilepsy Foundation Louisiana |
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Epilepsy Foundation of Alabama |
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Epilepsy Foundation of Greater Chicago |
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Epilepsy Foundation of Western Ohio |
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Epilepsy Foundation Western/Central Pennsylvania |
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Fair Hill Partners |
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Florida Psychiatric Society |
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Florida Society of Clinical Oncology |
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Florida Society of Neurology |
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Florida Society of Rheumatology |
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Florida State Hispanic Chamber of Commerce |
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Gay Men Aloud |
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Grand Prairie Services |
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Granite State Taxpayers |
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Hinds Behavioral Health Services (HBHS) |
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International Institute of Human Empowerment |
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Iowa Biotechnology Association |
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Iowa State Grange |
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Iris House, Inc. |
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Kaiser Clinical Research Services |
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Kenneth Young Center |
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Kentucky and Southern Indiana Stroke Association |
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Kentucky Diabetes Network |
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Kentucky Life Sciences Council |
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Kreider Services Inc |
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Lake County United |
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Louisiana Psychiatric Medical Association |
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Lupus Foundation New England |
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Lupus Foundation of Florida |
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Lupus Foundation of Southern California |
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Lupus LA |
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Lupus of Nevada, Inc. |
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Massachusetts Association for Mental Health |
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Medical Oncology Association of Southern California |
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Memorial Behavioral Health |
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Mental Health & Addiction Advocacy Coalition Mental Health America of Eastern Missouri |
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Mental Health America of Montana |
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Mental Health Association in New York State, Inc. |
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Mental Health Awareness Team |
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Michigan Biosciences Industry Association – MichBio |
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Michigan Medical Group Management Association |
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Minnesota Rural Health Association |
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Missouri Association of Osteopathic Physicians and Surgeons |
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Missouri Biotechnology Industry Organziation (MOBIO) |
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Molly's Fund Fighting Lupus |
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Montana BioScience Alliance |
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MS Resources |
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NAADAC-The Association for Addiction Professionals |
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