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Avalere Health Study Finds That Access to Key Drugs for Many Dual-Eligibles in California Has Been Reduced Under the New Medicare Benefit

Posted on: Tuesday, 21 March 2006, 09:01 CST

WASHINGTON, March 21 /PRNewswire/ -- A new analysis shows that many of California's one million dual-eligible beneficiaries receive inferior drug access to key drugs under Medicare Part D compared to their previous state- sponsored Medicaid coverage. The study, prepared by Avalere Health, was released by the California HealthCare Foundation and will be presented today to the California State Assembly.

Using its proprietary DataFrame(TM) tool, Avalere Health analyzed CMS' publicly available data from October 2005 to assess if drug coverage for California's dual-eligible beneficiaries is better or worse after the transition to Part D drug plans. Their evaluation of the ten prescription drug plans (PDPs) that accepted California's auto-assigned dual-eligible beneficiaries revealed many instances of inferior coverage when compared to previous coverage offered by Medi-Cal, the state Medicaid program:

* PDPs accepting dual-eligibles cover a low of 626 drugs and a high of 3,360. * While Medi-Cal covered 20 anti-psychotic drugs -- known for their tendency to work differently on each individual patient -- some auto- enrollment PDPs cover a low of 15 of the same drugs. Avalere's review of two subclasses of cardiovascular drugs showed that while Medi-Cal covered 26 drugs, auto-enrollment PDPs cover between 12-32 of these drugs. * Avalere's review of Part D auto-enrollment PDPs shows instances where up to 38% of anti-psychotic drugs required prior authorization by one PDP, marking a distinct departure from Medi-Cal's prior authorization practices for these drugs and opening the door for beneficiaries to experience disruptions in access to these medications.

The report also found evidence that certain federal intentions to extend protections had been met by the marketplace. A closer look at four classes of drugs -- including two designated as "protected" by the federal government and two that are unprotected -- showed that federal efforts to ensure broader coverage of protected classes of drugs generally improved access in California. For example, on average, 93% of anti-psychotics and anti- retroviral drugs are covered on drug plans offered in California, versus an average of 63% of anti-hypertensive and anti-cholesterol drugs.

"The wide variance in plans accepting dual-eligibles calls into question the appropriateness of the auto-assignment policy for enrolling this group of beneficiaries," said Jon Blum, vice president of Avalere Health and a contributing author to the paper.

In addition to its look at Californian dual-eligibles' coverage under the new drug benefit, Avalere's analysis of the California Part D marketplace revealed a number of data points that highlight the complex choices beneficiaries are experiencing nationally:

* There are a total of 164 drug plans in California. LA County residents have 71 plans to choose from. * Among these 164 plans, cost-sharing tiers range from two to eight tiers. Standard commercial drug plans average three tiers. * Among these 164 plans, the number of drugs on formulary ranges from 530 to 3,360 (out of an approximate 8,000 FDA approved drugs). * Monthly premiums range from $0.00 - $66.08, with deductibles ranging from $0 - $250.

"As Medicare beneficiaries learn to navigate these choices, policymakers and advocates should remain vigilant in their monitoring of issues and support of beneficiary education," said Chiquita White, a Medicaid expert at Avalere Health and a contributing author of the study.

One in four Californian Medicare beneficiaries is a dual-eligible, and one million of the 6.2 million national dual-eligibles live in California. Dual- eligibles are the only Medicare beneficiaries that were auto-enrolled into the Part D program.

The issue brief, entitled "The Medicare Drug Benefit: How Good Are the Options?" is available to download at http://www.chcf.org/topics/view.cfm?itemID=119451. The authors are Chiquita White, Eli Sprecher, Elizabeth Hinshaw, and Jon Blum, all of Avalere Health.

Editor's Note: Avalere Health experts will present these findings at a Joint Informational Hearing of the California State Assembly Health Committee and Assembly Long-Term Care Committee in Sacramento, California. Avalere's Jon Blum will present along with Stan Rosenstein of California Department of Health Services; Michael Negrete of the California Pharmacists Association; Greg Knoll, Legal Aid Society of San Diego; and Jeanne Finberg, National Senior Citizen Law Center among other experts. Blum's presentation will be available to download Wednesday from http://www.avalerehealth.net/.

Avalere Health is a leading advisory company focused on healthcare business strategy and public policy. It serves a diverse client base, which includes Fortune 500 healthcare technology companies, Federal government agencies, and major medical foundations. The company is organized into six practice areas -- Medicare, Medicaid, Reimbursement, Long-Term Care, Health Information Technology, and Education. Anchored by a comprehensive research engine and staffed by experts in business, medical product commercialization, and health policy, Avalere provides strategic guidance, objective analytic research, and quality educational programs focused on a wide range of healthcare issues facing our nation.

Further information can be obtained at http://www.avalerehealth.net/.

Avalere Health

CONTACT: Lindsey Spindle of Avalere Health, +1-202-207-1337,lspindle@avalerehealth.net

Web site: http://www.avalerehealth.net/http://www.chcf.org/topics/view.cfm?itemID=119451

Source: PRNewswire

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