Medicare Part D Data
Benefit Phase Variable
AcademyHealth Annual Meeting
Boston, MA
June 28, 2010
Part D Event Characteristics
New information to supplement
pp
the Part D
Event data includes:


benefit phase
utilization management
 Tier
Ti
 Step
 Quantity
Q
i limits
li i
 Prior authorization
2
2007 Standard Part D Benefit
Benefit Phases:
Pre‐ICL
Deductible
Total Spending:
$265
$2 400
$2,400
Coverage Gap Catastrophic coverage
(ICL phase)
$5 451 25
$5,451.25
75% Plan Pays
Coverage
Gap
80% Reinsurance
≈ 95%
Beneficiary Out of Pocket $265
A
Amounts
t
5% Coinsurance
$808.75
Beneficiary Liability
3
15% Plan Pays
25% Coinsurance
$3,850 TrOOP
Direct Subsidy/
Beneficiary Premium
Medicare Pays Reinsurance
Benefit Phases for Drug Events




Deductible
Pre-initial coverage
g limit (p
(pre-ICL))
Coverage gap (ICL exceeded)
Catastrophic coverage
Beneficiaries whose plans have different
benefit structures may enter benefit
phases at different times (or skip
phases).
4
Benefit Phase - Data Sources


Part D Enrollment Data - the plan beneficiary is
enrolled
ll d iin
CCW extract of plan information from CMS
administrative data

The type of organization (variables include plan type, org
type, demo type)


PDE data

5
The particular benefit structure for each plan (e.g., defined
standard benefit; variables include amounts for deductible
deductible,
ICL and OOPT [out of pocket threshold])
The benefit phase determination for every Part D event is
y accumulating
g all of the PDE costs for the beneficiary
y
made by
Overview: Methodology
For each beneficiary with covered Part D
events:
1. Prescription
esc pt o d
drug
ug e
events
e ts a
are
e so
sorted
ted in se
service
ce
date order
2 Gross drug costs and true out-of-pocket costs
2.
(TrOOP) are accumulated
3 For each covered Part D event,
3.
event the accumulated
gross drug costs are compared to the deductible,
ICL and TrOOP costs; and these are compared to
OOPT and assigned a benefit phase value
6
Methodology (cont.)
(cont )
Deductible phase
I accumulated
Is
l t d gross drug
d
costs
t between
b t
$0 – deductible
d d tibl li
limit
it ($265 ffor 2007)
2007). If so = deductible
d d tibl
phase.
No
Pre-Initial Coverage Limit (pre-ICL)
Is accumulated gross drug costs between deductible and ICL ($265.01 - $2,400)? If so= pre-ICL
phase.
No
Initial Coverage Limit (ICL)
Is accumulated TrOOP less than catastrophic coverage threshold ($3,850.00)? If so = ICL phase.
No
Catastrophic Coverage
Accumulated TrOOP is greater than catastrophic threshold = Catastrophic phase.
7
“Straddle”
Straddle” PDEs



8
The benefit phases depend on specific dollar
amounts
Accumulated costs rarely fall exactly on phase
boundaries, so a PDE may have costs that are
split between two phases (“Straddle” PDEs)
If there are multiple claims on a service date
where a straddle situation occurs,, then additional
sorting must be done on these PDEs to
g
the straddle
determine which PDE is assigned
benefit phase value
Benefit Phases
The
e two-digit
o d g be
benefit
e p
phase
ase variable
a ab e uses
intelligence for both digits.
1st digit = benefit phase at the start of fill
2nd digit
g =p
phase once the drug
g has been
dispensed.

9
Benefit Phases
10
Value
Description
blank
Event is for a non-covered drug as indicated by the Drug Coverage Status
C
Code
XX
Contract and Plan ID on the PDE does not link to the Plan Characteristics File
NA
The plan on the event does not report benefit information.
DD
Deductible phase
DP
Straddle claim between the Deductible and Pre-ICL phases
DI
Straddle claim between the Deductible and ICL (Gap) phases
DC
Straddle claim between the Deductible and Catastrophic phases
PP
Pre-ICL phase
PI
Straddle claim between the Pre-ICL and ICL phases
PC
Straddle claim between the Pre-ICL and Catastrophic phases
II
ICL (coverage gap or “donut
donut hole”)
hole ) phase
IC
Straddle claim between the ICL and Catastrophic phases
CC
Catastrophic phase
Example – Phases with Straddle
(2007 Standard Benefit)
Service Date

11
Gross Drug Cumulative TrOOP
Cost (GDC) GDC
Cumulative Benefit TrOOP
Phase
1/2/2007
$25.67
$25.67
$4.00
$4.00 DD
1/6/2007
$202.10
$227.77
$25.00
$29.00 DD
1/29/2007
$35.57
$263.34
$4.00
$33.00 DD
1/29/2007
$43.39
$306.73
$4.00
$37.00 DP
2/5/2007
$202.10
$508.83
$25.00
$62.00 PP
2/21/2007
$25.67
$534.50
$4.00
$66.00 PP
Ordering of claims on 1/29 was determined by examining the beneficiary
responsibility percentages (bene amount/total cost) for the PDEs on the
straddle day
Special Considerations
Some p
plans do not follow standard benefit
phases.



12
Plans have flexibility with regard to benefit
design (e.g., enhanced alternative plans)
PACE and employer direct plans do not report
details regarding the benefit structure (BP
value = NA)
Fixed capitated demonstrations travel through
b
benefit
fit phases
h
b
based
d on gross d
drug costt
thresholds (not beneficiary OOP amounts)
CMS Chronic Condition Data Warehouse
www.ccwdata.org
13
Visit us at the Exhibit: Booth # 212
Christopher Powers,
Pharm.D.
Purpose


15
To determine the proportion of beneficiaries with
gross drug
d
expenditures
dit
exceeding
di their
th i iinitial
iti l
coverage limit (i.e., reaching the coverage gap
phase) and Tr
True
eO
Out-Of-Pocket
t Of Pocket (TrOOP) costs
exceeding the catastrophic threshold of the Part D
benefit overall
benefit,
o erall and for subgroups
s bgro ps of beneficiaries
with chronic conditions.
To calculate the amount of time spent in the preinitial coverage limit (pre-ICL), coverage gap, and
catastrophic phases, overall and within subgroups
of beneficiaries with chronic conditions.
Sample Population
20% Medicare Sample from 2007
 Limited to:



12 months of Part D coverage
g
Fee-for-service only
 12 months of Part A and B and no HMO coverage


Excludes:

16
Aged (65+)
Beneficiaries for which benefit p
phase could not
be determined (e.g., in PACE plans, employer
p
plans)
)
Methodology



Part D Prescription Drug Event data
summarized
i db
by b
beneficiary
fi i
tto d
determine
t
i
minimum and maximum dates in each benefit
phase.
PDE phase summary data merged with
demographic and CCW Chronic Condition
flags.
g
Percent reaching each phase determined and
time in phased calculated.

17
Note: analyses conducted regardless of lowincome cost sharing subsidy status.
Results: Demographics and Conditions
N
ALL
Gender
Male
Female
Age
65-74
75-84
85-94
95+
Low Income Subsidy
No
Yes
18
% of
Sample
2,191,072
100%
760,039
1 431 033
1,431,033
34.7%
65 3%
65.3%
996,002
816,405
343,670
34,995
45.5%
37.3%
15.7%
1.6%
1,420,719
1
420 719
770,353
64.8%
64
8%
35.2%
N
Chronic Conditions
Ischemic Heart Disease
Diabetes
RA/ OA
Heart Failure
Osteoporosis
Alzheimer's and Related
Depression
Chronic Kidney Disease
COPD
Stroke / TIA
Prostate Cancer
Female Breast Cancer
Colorectal Cancer
A t MI
Acute
Lung Cancer
Endometrial Cancer
p
rates.
* Gender specific
787,736
631,803
545 093
545,093
430,583
340,558
307,423
262,299
259,786
259,202
108 488
108,488
62,113
49,937
21,764
18 815
18,815
16,213
3,739
% of
Sample
36.0%
28.8%
24 9%
24.9%
19.7%
15.5%
14.0%
12.0%
11.9%
11.8%
5 0%
5.0%
8.2% *
3.5% *
1.0%
0 9%
0.9%
0.7%
0.3% *
Percent Reaching Gap and Catastrophic
70.0%
60.0%
50.0%
40 0%
40.0%
30.0%
20.0%
10.0%
0.0%
19
Gap Only
Gap + Catastrophic
Time in Phase: Reached Gap
p Only
y
ALL
Alzheimer's and Related Female Breast Cancer
Female Breast Cancer
Depression
Chronic Kidney Disease
Heart Failure
COPD
Diabetes
Stroke / TIA
Ischemic Heart Disease
Lung Cancer
Prostate Cancer
RA / OA
A / OA
Acute MI
Osteoporosis
Endometrial Cancer
Endometrial Cancer
Colorectal Cancer
0
50
100
150
Days in Pre‐ICL
20
200
250
Days in Gap
300
350
Time in Phase: Reached Gap
p and Catastrophic
p
ALL
Lung Cancer
Colorectal Cancer
Colorectal Cancer
Chronic Kidney Disease
Depression
COPD
Prostate Cancer
Heart Failure
RA / OA
Osteoporosis
Diabetes
Alzheimer's and Related Ischemic Heart Disease
Ischemic Heart Disease
Endometrial Cancer
Stroke / TIA
Female Breast Cancer
e a e east Ca ce
Acute MI
0
50
100
Days in Pre‐ICL
21
150
Days in Gap
200
250
300
Days in Catastrophic
350
Conclusion
A larger proportion of beneficiaries with
chronic conditions exceeded their initial
coverage
g limit and catastrophic
p
coverage
g
threshold compared to the overall
population.
population
 Only moderate differences exist in the
amountt off time
ti
spentt various
i
Part
P t D phases
h
when comparing beneficiaries with chronic
conditions to the overall population.

22