The effect of the patient protection and Affordable Care Act on the Medicare Part D coverage gap

108 Pages·2017·2.99 MB·English

by  Jennifer A. Forristal

University of Louisville
ThinkIR: The University of Louisville's Institutional Repository
Electronic Theses and Dissertations
12-2015
The effect of the patient protection and Affordable
Care Act on the Medicare Part D coverage gap as
reflected in diabetes medication adherence.
Jennifer A. Forristal
University of Louisville
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Recommended Citation
Forristal, Jennifer A., "The effect of the patient protection and Affordable Care Act on the Medicare Part D coverage gap as reflected in
diabetes medication adherence." (2015).Electronic Theses and Dissertations.Paper 2315.
https://doi.org/10.18297/etd/2315
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THE EFFECT OF THE PATIENT PROTECTION AND
AFFORDABLE CARE ACT ON THE MEDICARE PART D
COVERAGE GAP AS REFLECTED IN DIABETES
MEDICATION ADHERENCE

By

Jennifer A Forristal

A Dissertation
Submitted to the Faculty of the
School of Public Health and Information Sciences of the
University of Louisville in Partial Fulfillment of the
Requirements for the Degree of
Doctor of Philosophy in Public Health Sciences

Department of Health Management and Systems Sciences
University of Louisville
Louisville, Kentucky

December 2015
2
THE EFFECT OF THE PATIENT PROTECTION AND
AFFORDABLE CARE ACT ON THE MEDICARE PART D
COVERAGE GAP AS REFLECTED IN DIABETES
MEDICATION ADHERENCE

By

Jennifer A Forristal

A
 Dissertation
 Approved
 on

November
 18,
 2015

By
 the
 following
 Dissertation
 Committee

Dissertation
 Director

Barry
 Wainscott,
 M.D.,
 MPH

Robert
 Esterhay,
 M.D.

Christian
 Furman,
 M.D.,
 MSPH

LaQuandra
 Nesbitt,
 M.D.,
 MPH

  ii
DEDICATION

  This is dedicated to my parents who instilled in me a love of learning and the
importance of education.

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ACKNOWLEDGEMENTS

I would like to thank my committee for their support, insight and constructive
criticism throughout this process. I am very grateful to Humana for the use of their data. I
want to acknowledge William Fleming for his advice, Fred Brownfield for his support
and Yihau Xu for her guidance.
I would like to thank my family for their love and support during this process
especially my husband, Jamieson and kids, Tyler and Addison, who sacrificed many
nights and weekends so I could focus on this work. My parents, Dave and Kathy Dively
and siblings, Daniel and Julie have always been a source of strength and encouragement.
I would like to thank my friends who have supported me in every endeavor,
especially Cyndi, Charlotte, Christine and Megan. I would like to thank all my fellow
public health students who suffered right along with me: Robin, Robyn, Katie, Christine,
Susan and Leslie, you are truly some of the smartest women I know.
I am blessed.
Ecclesiastes 12:12

  iv
ABSTRACT

THE
 EFFECT
 OF
 THE
 PATIENT
 PROTECTION
 AND

AFFORDABLE
 CARE
 ACT
 ON
 THE

MEDICARE
 PART
 D
 COVERAGE
 GAP
 AS
 REFLECTED
 IN

DIABETES
 MEDICATION
 ADHERENCE

Jennifer
 Forristal

November
 18,
 2015

Background: This dissertation involves an evaluation of the effect of the Patient
Protection and Affordable Care Act (ACA) on diabetic medication adherence as the
Medicare Part D coverage gap begins to close.
Purpose: The dissertation’s primary research question: will medication
adherence for Humana Medicare Part D health plan members filling diabetic medications
at Humana’s mail order pharmacy improve as the coverage gap is incrementally closed
due to the ACA? The study had 3 objectives: 1) to evaluate diabetes medication
adherence of health plan members before they reach the coverage gap and then while
they are in the coverage gap, 2) to compare diabetes medication adherence between two
similar groups with differing benefit structures, one group with a gap in coverage as
opposed to a group with no benefit changes within the year and 3) to examine diabetes
medication adherence trend over multiple years as the coverage gap is closed.
Methods: A retrospective, pre-post cohort analysis with control group study
design was used to assess the study objectives. The control group consisted of low-

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income subsidy (LIS) members with no gap in coverage and the treatment group reached
the coverage gap.
Results: Brand and generic medication users exhibited decreases in adherence
once they entered the coverage gap although significant differences were seen for all
years in the brand cohort only. The control group exhibited better adherence than the
treatment group. The control group also exhibited stable adherence year over year while
the treatment group realized a decline.
Conclusions: The results of this study indicate that being in the coverage gap was
a significant indicator of a decrease in adherence for health plan members on brand
diabetic medications. While the study findings showed a decrease rather than an increase
in the treatment group medication adherence year over year, the results did indicate no
significant changes in the control group. The expectation would be that once the coverage
gap is fully closed in 2020, the treatment group would exhibit similar behavior. Both
groups exhibited high adherence overall suggesting the mail order dispensing channel
could have an effect on adherence.
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TABLE OF CONTENTS

DEDICATION
 ............................................................................................................................................
 iii

ACKNOWLEDGEMENTS
 ....................................................................................................................
 iv

ABSTRACT
 ..................................................................................................................................................
 v

LIST OF TABLES
 .....................................................................................................................................
 ix

LIST OF FIGURES
 ...................................................................................................................................
 xi

CHAPTER 1
 ..................................................................................................................................................
 1

INTRODUCTION
 .......................................................................................................................................
 1

Background to the Study
 ......................................................................................................................
 1

The Importance of Adherence in Public Health
 ...........................................................................
 2

The Importance of Adherence in Diabetes
 .....................................................................................
 5

The Medicare Modernization Act of 2003
 ..................................................................................
 10

The Patient Protection and Affordable Care Act
 ......................................................................
 11

The Effect of Cost-Sharing and Copayments on Adherence
 ................................................
 12

Proposed Reform Effects
 ..................................................................................................................
 15

Statement of the Problem
 ..................................................................................................................
 16

Purpose of the Study
 ...........................................................................................................................
 17

Research Question and Hypotheses
 ...............................................................................................
 18

Summary
 .................................................................................................................................................
 19

CHAPTER 2
 ...............................................................................................................................................
 21

LITERATURE REVIEW
 ......................................................................................................................
 21

Theoretical Framework
 ......................................................................................................................
 21

Economic Theory
 .................................................................................................................................
 21

Andersen's Behavioral Model of Health Services Use
 ............................................................
 23

CHAPTER 3
 ...............................................................................................................................................
 29

METHODS
 .................................................................................................................................................
 29

Study Design
 .........................................................................................................................................
 29

Population
 ..............................................................................................................................................
 29

Eligibility Criteria
 ................................................................................................................................
 31

Description of study variables
 .........................................................................................................
 33

a) Independent Variable
 ................................................................................................................
 33

b) Dependent Variable or Outcome Measure
 ........................................................................
 36

Propensity Score Matching
 ...............................................................................................................
 39

Data analyses required to address objectives:
 ............................................................................
 41

Confidentiality
 ......................................................................................................................................
 43

Summary
 .................................................................................................................................................
 43

CHAPTER 4
 ...............................................................................................................................................
 45

RESULTS
 ...................................................................................................................................................
 45

Study Population
 ..................................................................................................................................
 45

Coverage gap
 .........................................................................................................................................
 49

Coverage gap month
 ...........................................................................................................................
 49

Descriptive analyses of pre-coverage gap and within coverage gap medication
adherence
 ................................................................................................................................................
 53

Propensity score matching
 ................................................................................................................
 56

Descriptive analyses of propensity score matched control and treatment groups
 ..........
 63

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Diabetic medication adherence across plan years
 .....................................................................
 64

Summary
 .................................................................................................................................................
 66

CHAPTER 5
 ...............................................................................................................................................
 67

DISCUSSION
 ............................................................................................................................................
 67

Coverage Gap
 ........................................................................................................................................
 67

Pre-coverage gap and within coverage gap medication adherence
 .....................................
 72

Demographics for propensity score matched groups
 ...............................................................
 75

Medication adherence in control and treatment groups
 ..........................................................
 76

Medication adherence across plan years
 ......................................................................................
 78

Strengths and Limitations
 .................................................................................................................
 80

Findings and recommendations for future research
 .................................................................
 81

Summary
 .................................................................................................................................................
 83

REFERENCES
 ..........................................................................................................................................
 85

APPENDIX I
 ..............................................................................................................................................
 89

GLOSSARY
 ...............................................................................................................................................
 89

APPENDIX II
 ............................................................................................................................................
 91

UNIVERSITY OF LOUISVILLE INSTITUTIONAL REVIEW BOARD
DETERMINATION
 ................................................................................................................................
 91

CURRICULUM VITAE
 ........................................................................................................................
 94

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