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Medicare Modernization Act Did Not Change Chemotherapy As Feared

DURHAM, N.C. -- Cancer patients receiving chemotherapy have not noticed a restriction in their access to treatment following the enactment of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), despite the act's significant reduction in government reimbursement to oncologists, according to a new study led by researchers in the Duke Clinical Research Institute (DCRI).

"Critics of the MMA often said that it would reduce patients' access to chemotherapy services, because doctors would receive 30 to 40 percent less reimbursement from the government for administering treatment," said Kevin Schulman, M.D., director of the DCRI's Center for Clinical and Genetic Economics, and senior investigator on the study. "Our study showed that patients actually do not perceive barriers to their access to chemotherapy and perceptions about access are really the same among patients who received treatment before the legislation went into effect, and those who received it afterwards."

The team's findings will be published in the November 15, 2007 print edition of the journal Cancer, but also will appear earlier in the journal's October 8, 2007 online edition. The study was funded by a grant from the National Patient Advocate Foundation's Global Access Project, which brings together 42 national healthcare stakeholder groups -- such as pharmaceutical companies and advocacy groups -- to fund health research projects. The Project has focused on examining the MMA's consequences for patients, providers and healthcare systems.

The Duke researchers examined the results of 1421 surveys completed via the internet by 684 patients who had received chemotherapy prior to the enactment of the MMA and 737 patients who were treated after it went into effect. Respondents answered questions related to issues including the amount of time they waited to start chemotherapy after their initial cancer diagnosis, and how far they had to travel to get their treatments.

"When the act was passed in 2003, many doctors and patient advocates were concerned about the consolidation of services it might necessitate, such as the moving of chemotherapy services to hospital rather than outpatient settings and the elimination of staff positions," said Joelle Friedman, a DCRI researcher and lead author on the paper. "They were afraid these changes would affect patients' access to care, but our study showed that these concerns turned out to be largely unwarranted."

About half of the patients surveyed in each group were under the age of 65 and half were over 65. The majority of patients in each group reported being either satisfied or very satisfied with the care they received from their oncologists, Friedman said.

The researchers also found no difference in the amount of time from diagnosis to initiation of chemotherapy between the two groups; the median lapse in time was 22 days in both groups, Friedman said.

Patients reported an average travel time of 30 minutes to the location of their chemotherapy appointments, both before and after the implementation of the act, she said.

The speculation that treatment location would change -- that patients would either be forced to travel farther for therapy or switch treatment locations in the middle of therapy -- also proved to be unfounded, Friedman said.

The MMA represented the largest overhaul of the Medicare system since it was created in 1965. Changes included a new prescription drug benefit, and a $25 billion allocation of funds to rural hospitals. One key provision, however, was a significant reduction in Medicare reimbursement to healthcare providers. Oncologists were strongly affected, due to a perception that they had been over-compensated in the past.

Other researchers involved with this study were Lesley Curtis, Bradley Hammill, Jatinder Dhillon, Charles Weaver, Sugata Biswas and Amy Abernethy.

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  • 3 months later...

Granted, the new Medicare D program was filled with lots of holes. The biggest problem was in designing the program. This administration did not want the Medicare drug benefit to be administered directly by the federal government (where Medicare is run efficiently). Instead, it devised a public program run by hundreds of competing private plans, each with its own prices and coverage policies.

Also, a joint Michigan/Harvard study confirmed, before the new Medicare reform, medical oncologists were more likely to choose cancer drugs that earn them more money. Yet a survey published in "Patterns of Care" showed that the Medicare reforms have not solved the problem of variations in oncology practice.

http://www.healthyskepticism.org/global ... in2007-06/

However, the new Medicare drug benefit plan was part of a much broader message. With oncology drugs accounting for about 69% of total Part B spending on prescription drugs and related services, the new Medicare D plan made it more important for Senior cancer patients.

A study published in the journal Health Affairs discovered that Part D expanded access to cancer therapies and required only low co-payments. Researchers found that the most commonly prescribed cancer drugs were available and when a brand-name drug was not covered, its generic equivalent was.

Apparently Medicare has gone far in accomplishing the task of making many cancer drugs available to our Seniors. Nearly all generic cancer drugs and 70% of brand-name cancer drugs are covered by the Part D plans. Most of the brand-name drugs not covered had generic equivalents that are covered. Also, a number of trusted old generic agents have been found to be just as effacious as the more expensive brand name ones.

According to NCI's official cancer information website on "state of the art" chemotherapy, no data support the superiority of any particular regimen. So, it would appear that published reports of clinical trials provide precious little in the way of guidance. There are many cancer drug regimens, all of which have approximately the same probability of working. The tumors of different patients have different responses to chemotherapy.

Medical oncologists are now be reimbursed for providing evaluation and management services, making referrals for diagnostic testing, radiaiton therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival. In other words, medical oncologists were taken out of the retail pharmacy business. However, as Medicare tried to do this, private insurance plans still go along with the chemotherapy concession.

Now, if only Medicare would be allowed to negotiate prices, eliminate the doughnut hole, and stop subsidizing private insurance Medicare plans!

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  • 7 months later...
  • 7 months later...

An unintended effect of the Medicare Part D benefit could be the creation of the world's most valuable resource for understanding how drugs are used, especially by the elderly and the chronically ill, and their risks and benefits. This resource would be created by linking information on drug dispensing to patients' other health information. Medicare data are available for more than 40 million people. These data can transform our ability to assess drugs under real-life conditions, particularly in this vulnerable population, which is often underrepresented in clinical trials. However, in order to realize this benefit, we must make it a priority, justify it to the public, and provide adequate funding.

To understand the opportunity before us, it helps to understand how little we know now. The Food and Drug Administration (FDA) often approves a drug for long-term use on the basis of minimal long-term safety data: as few as 100 people may have been followed for adverse effects in studies lasting at least one year. Furthermore, the FDA rarely can compel manufacturers to conduct postapproval studies. The current mainstay for drug safety is the spontaneous reporting of adverse events to the FDA's MedWatch program, which suffers from underreporting, variable data quality, and the lack of a mechanism to assess confounding risk factors. Spontaneous reports are a particularly poor instrument for detecting increased risks of common conditions, such as cardiac disease, that greatly affect public health.

The lack of systematic collection and analysis of post-marketing data on the use of drugs and the outcomes of treatment has delayed the discovery of some serious problems until after millions of people have been exposed. For example, cisapride (Propulsid) was withdrawn because it had been prescribed to many people with contraindications, and several coxibs are now known to increase the risk of myocardial infarction.

Two existing programs share features that can be adopted for Medicare data. First, the Vaccine Safety Datalink Project of the Centers for Disease Control and Prevention, which involves the use of linked data from health plans, is an invaluable source of data on vaccine safety. Second, the FDA makes some use of linked pharmacy and administrative records from health plans. These databases identify everyone who is eligible to receive a drug or vaccine, the starting and stopping dates of administration, and many outcomes and coexisting medical conditions. In addition to being useful for safety studies, these data sometimes allow assessment of the effectiveness of different therapies under conditions of actual use.

There are important limitations to these data, however. They do not identify some conditions with sufficient specificity, contain no information on actual drug ingestion, lack important information such as smoking status and body-mass index, often lack historical information, and include only drugs covered by the health plan. Therefore, it is important to review patients' full medical records in the small number of cases in which this information is critical.

Some prerequisites already exist for using Medicare data linked with data from health plans to study the use, risks, and benefits of drugs. Most important, the Centers for Medicare and Medicaid Services (CMS) has proposed linking Medicare drug claims with diagnosis and procedure claims. In addition, the FDA has experience in working with linked data and in collaborating with expert groups such as the Centers for Education and Research on Therapeutics (funded by the Agency for Healthcare Research and Quality and administered by that agency in collaboration with the FDA).

To take advantage of the opportunity at hand, the CMS must carry out its proposal of creating a fully linked data set and ensure that it remains current. The CMS, the FDA, and their designees will need the ability to review selected outpatient and inpatient records. These agencies will need to clarify their authority to perform these reviews and explain their purpose satisfactorily to clinicians and patients. Finally, the FDA and other agencies will need new sources of funding if they are to use this information meaningfully and to conduct research on new methods for using it optimally. Additional issues, such as a means of sharing these data with researchers and others, must also be addressed.

Medicare data will offer a great opportunity to improve our ability to understand the balance of benefits and risks of drug treatment. If we take advantage of this opportunity, we will know much more about whether drugs are used as intended, whether they have their intended effects, and how risky they are.

Source Information

Dr. Platt is a professor in and chair of the Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, and principal investigator of the HMO Research Network Center for Education and Research on Therapeutics, Boston, and principal investigator of an FDA contract (HHSF 223200510010C) to perform post-marketing surveillance for drug risks and benefits. Dr. Ommaya is a senior staff member at the Institute of Medicine, Washington D.C.

The New England Journal of Medicine

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  • 6 months later...

(Ivanhoe Newswire) -- Cuts in reimbursement for cancer care in 2003 have not affected the care of patients, at least not from the patients perception, according to a new study. The research reveals patients remain highly satisfied with their cancer treatments.

In 2003, the Medicare Prescription Drug, Improvement and Modernization Act (MMA) was signed into law by President Bush. It was the most comprehensive restructuring of the Medicare system since it began in 1965. One of the changes included reductions in Medicare reimbursement to health care cancer providers, which went into effect in 2005. Some pointed out this would require patients to travel further for treatment because cancer centers would have to downsize with less money.

Researchers from Duke Clinical Research Institute conducted a web-based survey interviewing patients before and after MMA went into effect. The research included 1,421 cancer patients with 684 treated before MMA and 737 treated after MMA. Study authors wanted to compare the patients perceptions of access to and satisfaction with their oncologists care.

Overall, there was no significant difference between the two groups. Both groups reported an average of 21 days for treatment to begin and an average travel time of 30 minutes. Both groups also reported being very satisfied with their medical care. While authors say this study does not support the generalizations that patients are being affected by the MMA changes, they add further examination of rural areas and those where only Medicare insurance is needed.

SOURCE: CANCER, published online October 8, 2007

The Medicare Modernization Act changed how the CMS pays for doctor-administered drugs to a system based on doctors' costs for the drugs from one based on average wholesale price. The government wasn't reducing payment for cancer care, it was simply reducing overpayment for cancer drugs. The government can't afford to overpay for these drugs in an era which they are fantastically expensive.

Medical oncologists are now reimbursed for providing evaluation and management services, making referrals for diagnostic testing, radiation therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival.

The fact that medical oncologists received no reimbursement for providing oral-dose therapy to patients had been the principal barrier to the availability of oral-dose protocol. The advent of oral agents ultimately means that medical oncology will need to change its identity, prior to the chemotherapy concession. However, while Medicare tried to remove the profit incentive from the choice of cancer treatment, private payors still go along with it.

The new legislation started the process of providing access to a "full range" of the latest cancer-related prescription drugs to enhance the quality and standard of treatment for cancer. Medicare recipients were being relagated to treating their diseases with older, more toxic infusional chemotherapy agents at a time when new and more promising cancer drugs were reaching the market.

Compared to infusional therapy, oral-dose anti-cancer drugs can make receiving cancer treatment more convenient for patients by allowing flexibility in taking medication without disrupting work or other activities. They can often result in less time (or no time) spent in office-based oncology practices because of the absence of intravenous administration and its related side-effects.

The new "targeted" cancer therapies gave doctors a better way to tailor cancer treatment. There are a multiple of different cancer drug regimens, all of which have approximately the same probability of working. Treatments may be individualized based on the unique set of molecular targets produced by the patient's tumor, and these important treatment advances will require personalizing treatment based on testing the biological profiles of each patient's cancer.

What was needed, was to remove the profit incentive from the choice of cancer treatments, which were financial incentives for infusion therapy over oral therapy or non-chemotherapy, and financial incentives for choosing some drugs over others. Patients should receive what is best for them and not what is best for their oncologists.

The new system is clearly an improvement from the standpoint of cancer patients, taxpayers, and advocates of basing drug selection on individual tumor biology, rather than on a least common denominator approach which invites "conflict-of-interest medical decision-making." But again, private payors still go along with the concession.

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  • 8 months later...

Chemotherapy patients have not lost access to care despite federal legislation that has reduced reimbursements to their doctors in recent years, a new report finds.

Critics feared the passing of the Medicare Modernization Act of 2003 would make treatment more difficult, but investigators from the Duke Clinical Research Institute (DCRI) found little difference in the distance chemo patients traveled to be treated and the time between diagnosis and start of treatment.

"The Medicare Modernization Act took issue with the fact that oncologists were often reimbursed too much -- sometimes as much as three times what they had paid -- for the chemotherapy drugs they were giving their patients, and subsequently, doctors saw those reimbursement payments fall," senior study investigator Dr. Kevin Schulman, director of the DCRI's Center for Clinical and Genetic Economics, said in a prepared statement. "The concern was that patient care would suffer if doctors had to close their practices or scale back, making it necessary for patients to travel farther or go to inpatient facilities for treatment. Our study showed that this, in fact, has not yet occurred."

The researchers studied the treatment of people with leukemia, lymphoma, breast, lung or colorectal cancer from across the United States from 2003, before the act passed, through 2006.

"The distance patients traveled for chemotherapy treatments did not considerably increase after passage of the act," lead investigator Lesley Curtis, a health services researcher in the DCRI, said in a prepared statement. "And despite concerns that patients would have to go to inpatient settings with longer wait times to be treated, we observed a small shift in the provision of initial chemotherapy from inpatient to outpatient settings between 2003 and 2006."

The median amount of time between diagnosis and chemotherapy was 28 days and did not change significantly, regardless of the treatment settings between 2003 and 2006, Curtis said.

"We did find that patients in rural areas tended to have to wait longer to begin their chemotherapy after diagnosis -- their wait times increased by up to five days from 2003 to 2006," Curtis said. "Whether this is something that could have a negative effect on treatment outcomes is still unknown, but it is something we should continue to follow."

The findings were published in the July 9 issue of theJournal of the American Medical Association.

The lower reimbursement may still have long-term effects that have yet to be realized, Curtis cautioned.

SOURCE: Duke University Medical Center, news release, July 8, 2008

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  • 3 months later...

In a rare bit of good news for taxpayers, the cost of the Medicare prescription drug program fell $6 billion this year — savings driven by the widespread use of low-cost generic drugs.

The prescription drug program for seniors has cost about one-third less — about $50 billion — than originally estimated since it started in January 2006.

http://www.usatoday.com/news/health/200 ... titialskip

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  • 1 year later...

At the 14th annual conference of the National Comprehensive Cancer Network, there was a roundtable discussion about rewarding doctors for whole patient care - not just treatments.

Doctors are rewarded for mechanical acts - administering chemotherapy and radiation, performing surgery. We need to reward physicians for treatment of the whole patient, not just treatment of the disease. There is a need for care planning and coordination that begins at the time of cancer treatment and continues post-treatment and throughout survivorship.

Congressional Representative Lois Capps of California was supposed to reintroduce legislation that would provide Medicare reimburesment for the development of written treatment plans and summaries and the discussion of those plans between doctors and patients.

I thought the Medicare Modernization Act of 2003 was supposed to start reimbursing medical oncologists for providing evaluation and management services, making referrels for diagnostic testing, radiation therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival?

Many cancer experts agree that survivorship care planning is essential to providing quality cancer care. Some of the most recent evidence can be found in the Institute of Medicine (IOM) report, From Cancer Patient to Cancer Survivor: Lost in Transition. Additional evidence can be found in earlier IOM reports, such as Ensuring Quality Cancer Care.

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  • 4 months later...

How Medicare’s Payment Cuts For Cancer Chemotherapy Drugs Changed Patterns Of Treatment

Mireille Jacobson1, Craig C. Earle2, Mary Price3 and Joseph P. Newhouse4

1 Mireille Jacobson (mjacobso@rand.org ) is a senior health economist at the RAND Corporation, in Santa Monica, California, and a faculty research fellow of the National Bureau of Economic Research.

2 Craig C. Earle is director of the Health Services Research Program at Cancer Care Ontario and the Ontario Institute for Cancer Research, in Toronto.

3 Mary Price is a programmer with the Center for Health Policy Studies, Division of Research, Kaiser Permanente, in Oakland, California.

4 Joseph P. Newhouse is the John D. MacArthur Professor of Health Policy and Management at Harvard University, in Boston, Massachusetts, and a research associate of the National Bureau of Economic Research.


The Medicare Prescription Drug, Improvement, and Modernization Act, enacted in 2003, substantially reduced payment rates for chemotherapy drugs administered on an outpatient basis starting in January 2005. We assessed how these reductions affected the likelihood and setting of chemotherapy treatment for Medicare beneficiaries with newly diagnosed lung cancer, as well as the types of agents they received. Contrary to concerns about access, we found that the changes actually increased the likelihood that lung cancer patients received chemotherapy. The type of chemotherapy agents administered also changed. Physicians switched from dispensing the drugs that experienced the largest cuts in profitability, carboplatin and paclitaxel, to other high-margin drugs, like docetaxel. We do not know what the effect was on cancer patients, but these changes may have offset some of the savings projected from passage of the legislation. The ultimate message is that payment reforms have real consequences and should be undertaken with caution.

Key Words: Physician Payment • Medicare

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 substantially reduced reimbursements for outpatient chemotherapy drugs. Prior to the act’s passage, Medicare reimbursed such drugs at the lesser of the charge billed for the drugs, or 95 percent of the average wholesale price (AWP) of the drugs. Many drugs were widely available to physicians at costs averaging 13–34 percent below the average wholesale price, and some agents were priced significantly lower. (At the same time, Medicare paid what many oncologists viewed as a below-cost fee for them to administer the drugs.) The net effect was that physicians and outpatient clinics administering the drugs were able to "buy" them on the open market at one price and "sell" them to Medicare patients at a higher price.

The large discrepancy between payment rates and acquisition costs for these drugs was identified as early as 1997. The then-named General Accounting Office, now the Government Accountability Office, reported widely available discounts of about 20 percent below average wholesale price for two drugs, carboplatin and paclitaxel, in 2001. A later analysis calculated that reimbursement for paclitaxel in 2004 was six times higher than actual cost. These reports documented that these chemotherapy purchase prices were well below Medicare reimbursement rates. As a result, the Medicare reform law aimed to lower Medicare spending by reducing reimbursements for specific drugs. It also aimed to reduce the incentive to prescribe certain drugs that afforded particularly higher margins for the doctors and clinics but did not offer any clear clinical advantage for patients.

Under the law, starting 1 January 2004, Medicare first lowered reimbursements on the drugs from 95 percent to 85 percent of average wholesale price as of 1 April 2003. Then, on 1 January 2005, Medicare instituted a new payment system based on a so-called average sales price. Under this system, Medicare reimburses chemotherapy agents based on manufacturers’ average national sales prices over the previous two quarters plus 6 percent to ensure adequate reimbursement to providers facing above-average drug costs. Medicare also began paying physicians an increased fee for administering the drugs, to better approximate physicians’ and clinics’ actual costs.

The new payment system set chemotherapy reimbursements at 1.06 times the average costs of the drugs. This rate represented a notable decline from the 2004 weighted average payment-to-cost ratio of 1.22. Comprehensive estimates of what this ratio was prior to 2004 are unavailable, but it was likely higher since reimbursement as a percentage of average wholesale price was higher.

The implicit reduction in margins for oncology drugs raised important concerns about cancer treatment. Many feared that the legislation’s reimbursement change would reduce access to cancer chemotherapy for Medicare beneficiaries. Community oncologists worried that the law would make it too unprofitable to treat cancer patients, forcing them to shift some beneficiaries from their offices to hospitals, where the patients might face treatment delays.

Previously published studies have found no evidence that cancer patients on Medicare experienced delays in chemotherapy treatment. To date, however, no work has formally assessed whether the likelihood of receiving chemotherapy in the first place has changed, or whether the administered agents have changed. Our study was designed to determine the answers.

http://content.healthaffairs.org/cgi/co ... 009.0563v1

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The findings of this paper add to the survey done by Dr. Neil Love, entitled "Patterns of Care" http://patternsofcare.com/2005/1/editor.htm

In Jacobson and colleagues' study, physicians switched from dispensing the drugs that experienced the largest cuts in profitability, carboplatin and paclitaxel, to other high-margin drugs, like docetaxel.

One of the results of Dr. Love's survey shows that for first-line chemotherapy of metastatic breast cancer, 84-88% of the academic center- based oncologists (who do not derive personal profit from infusion chemotherapy) prescribed an oral dose drug (capecitabine), while only 13% prescribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel.

In contrast, among the community-based oncologists (who do derive personal profit from infusion chemotherapy), only 18% prescribed the oral dose drug (capecitabine), while 75% prescribed infusion drugs, and 29% prescribed the expensive, highly remunerative drug docetaxel. (Patterns of Care: 2005,Vol 2,Issue 1).

While Newhouse and Earle's previous Michigan/Harvard study, "Does reimbursement influence chemotherapy treatment for cancer patients?" [Health Affairs 25, no. 2 (2006)] showed results before the new Medicare reform, Love's "Patterns of Care" study showed results that the Medicare reforms were still not working. This new study adds another "smoking gun" about the chemotherapy concession issue.

I believe that all of these studies showed results that the Medicare reforms are still not working. An impossible conflict of interest still exists. And the existence of this profit motive in drug selection has been one of the major factors working against the individualization of cancer chemotherapy based on testing the cancer biology. It is way past time to take medical oncologists out of the retail pharmacy business and let them be doctors again.

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  • 4 weeks later...

A number of cancer patients die of heart failure, brought on by the intense (over-aggressive cocktail) regimes of chemotherapy.

Taxol (paclitaxel) is an extremely potent chemotherapy drug, often producing a number of side effects in patients, such as cardivascular problems: hypertension or problems with the heart, such as arrhythmias, congestive heart failure or bradycardia. Many patients on chemotherapy become anemic and that can trigger further cardiac complications.

Chemotherapy in general can have a deadly side effect: heart trouble. However, the "antimicrotubules" class of chemotherapy drugs, of which Taxol is a member, is supposed to be relatively rare (they really don't know). The Platins (Carboplatin and Cisplatin) may be much different. Heart problems are more common than people think, affecting up to 25% of cancer patients.

According to MD Anderson cardiologists, many doctors do not adequately monitor their patients or manage their care to minimize the health risk. Chemotherapy can help achieve a clinical response (remission), but treatments can also hurt heart muscle by reducing the hearts ability to pump.

Problems can range from insignificant to so severe that a patient can die from the heart damage rather than the cancer itself. In many cases, cancer treatment heart damage isn't detected until it is advanced because traditional heart imaging tools often miss heart muscle damage.

Medicare Part D may be helping more older Americans with heart failure get medication used to control the disease. A new study of nearly 7,000 older heart failure patients in a big insurance plan found the number of filled prescriptions for standard heart failure medication increased after Part D began in 2006, and the biggest increase was among seniors who previously lacked drug coverage.

The results, which were reported in the American Heart Journal, are the first to show Part D may help more people with heart failure get meds that are recommended to lower the risk of hospitalization and extend lives.

The study examined records for 6,950 people age 65 and older who were enrolled in a Pennsylvania Medicare managed care plan between 2003 and 2007. In the year before Part D began, 534 plan members had no coverage, and 4,600 had coverage with quarterly caps of $150 or $350. The remaining 1,800 had coverage through an employer or union, with no cap, the news service reports.

Among those who had lacked coverage, the average number of scrips filled each year rose from 13 to 19, and the percentage who filled at least one scrip for a beta-blocker increased from 45% in the two years prior to Part D, to 59% in 2006 and 2007. For a beta-blocker plus an ACE inhibitor or ARB, the percentage rose from 21% to 32%. Plan members who previously had drug coverage with quarterly caps showed smaller increases. The percentage filling a scrip a beta-blocker rose from between 55 and 58% to about 63%.

Julie Donohue of the University of Pittsburgh Donohue said that these findings are consistent with a major goal of the (Medicare Part D) policy, which was to reduce financial barriers to medication access among the elderly.

Source: American Heart Journal Volume 160, Issue 1, Pages 159-165 (July 2010)

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  • 5 months later...

I worry every day about the long term effects of extended cancer treatments. Now on Tarceva, my PCP is monitoring my blood counts in between trips to MDA in Orlando. He and I have had the heart conversation. An EKG was always included in my annual physical pre-cancer dx (I was already on bp med) but now I'm getting an Echogram as well. They monitor in different ways. Don't know if I would be taking the precautions I am if it were not for Medicare (and for those who don't know, we pay for it) and the supplemental insurance we have. I'm sure for those who can't afford the supplemental ins, Medicare care mean the difference between extended life and early death.

Judy in KW

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