Medicare Part D and Long-Term Care: A Systematic Review of Quantitative and Qualitative Evidence
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In the largest overhaul to Medicare since its creation in 1965, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established Part D in 2006 to improve access to essential medication among disabled and older Americans. Despite previous evidence of a positive impact on the general Medicare population, Part D’s overall effects on long-term care (LTC) are unknown.
The purpose of this systematic review was to evaluate the literature regarding Part D’s impact on the LTC context, specifically costs to LTC residents, providers and payers; prescription drug coverage and utilization; and clinical and administrative outcomes.
Four electronic databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Business Fulltext Elite and Science Citation Index Expanded], selected US government and non-profit websites, and bibliographies were searched for quantitative and qualitative studies characterizing Part D in the LTC context. Searches were limited to studies that may have been published between 1 January 2006 (date of Part D implementation) and 8 January 2013.
Systematic searches identified 1,624 publications for a three-stage (title, abstract and full-text) review. Included publications were in English language; based in the US; assessed Part D-related outcomes; and included or were directly relevant to LTC residents or settings. News articles, reviews, opinion pieces, letters or commentaries; case reports or case series; simulation or modeling studies; and summaries that did not report original data were excluded.
Study appraisal and synthesis methods
A standardized form was used to abstract study type, study design, LTC setting, sources of data, method of data collection, time periods assessed, unit of observation, outcomes and results. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies.
Eleven quantitative and eight qualitative studies met inclusion criteria. In the seven years since its implementation, Part D decreased out-of-pocket costs among enrolled nursing home residents and potentially increased costs borne by LTC facilities. Coverage of prescription drugs frequently used by older adults was adequate, except for certain drugs and alternative formulations of importance to LTC residents. The use of medications that raise safety concerns was decreased, but overall drug utilization may have been unaffected. Although there was uncertain impact on clinical outcomes, quantitative studies demonstrated evidence of unintended health consequences. Qualitative studies consistently revealed increased administrative burden among providers.
Empirical evidence of Part D’s LTC impact was sparse. Due to limitations in available types of data, quantitative studies were generically lacking in methodological rigor. Qualitative studies suffered from lack of clarity of reporting. As future studies use clinical Medicare data, study quality is expected to improve.
Although LTC-specific policies continue to evolve, it appears that the prescription drug benefit may require further modifications to more effectively provide for LTC residents’ unique medication needs and improve their health outcomes. Adjustments may be needed for Part D to be more compatible with LTC prescription drug delivery processes.
KeywordsPrescription Drug Medicare Beneficiary Skilled Nursing Facility Assisted Living Facility Prescription Drug Coverage
Dr. Briesacher conceived of the overall study objective. Ms. Pimentel acquired, analyzed and interpreted the data, and wrote the manuscript. Drs. Briesacher and Lapane made substantive revisions to the manuscript and approved the final submitted version.
There was no funding source for this study. During the preparation of this manuscript, Dr. Briesacher was supported by research scientist award K01AG031836. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging. All authors declare that no potential conflicts of interest exist, including financial interests or affiliations relevant to the subject of this review.
We gratefully acknowledge Drs. Jane Saczynski, Jerry Gurwitz, Robin Clark, Allison Rosen, Marc Philip Pimentel and Ms. Alexandra Hajduk for their guidance and helpful comments on earlier versions of this manuscript. We sincerely thank Ms. Sally Gore for her assistance in developing our systematic search strategy.
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