How Does Changes to Medicare Part D Reimbursement Impact Adherence?


The federal government previously ruled that dual eligibles would need to use the Medicare part D program for prescriptions preferentially.

HIV infection is closely associated with the receipt of Medicare or Medicaid benefits. Medicare, which covers Americans who are 65 years of age or older and all people who have permanent disabilities and receive Social Security Disability insurance, is a federal program. Medicaid on the other hand is a state program covering low-income individuals.

Together, these programs cover 56% of Americans who have HIV. Additionally, roughly 10% of individuals with HIV are people who are eligible for both Medicare and Medicaid. When that is the case, Medicare is the primary insurer and Medicaid absorbs costs not covered by Medicare. Patients who have HIV also have a safety net called the AIDS Drug Assistance Program (ADAP), and its specific focus is prescription drug coverage.

A new publication in the journal Medical Care discusses changes in payment systems and utilization management after Medicare part D was implemented on January 1, 2006. At that time, the federal government made a decision that dual eligibles would need to use the Medicare part D program for prescriptions preferentially.

At the time of the change, a number of experts predicted the patients would be unable to receive their antiretroviral treatment (ART) in both the short- and long-term. Subsequently they expected to see decreased ART adherence and increased viral loads.

This study, the first of its kind to estimate the actual effect of the switch to Medicare part D, looks at out-of-pocket prescription drug spending, reliance on ADAP, ART adherence, and viral suppression. Most of the study participants were younger than 65, indicating that they were dually eligible by virtue of disability, not age.

It confirms that out-of-pocket spending for prescription drugs in individuals with HIV increased. Sixty percent of the 801 respondents indicated that they had incurred additional expense. The increases were precipitous and high at the beginning of transition, fell somewhat over time, but remained above baseline levels.

However, patients remained adherent to their ART, and viral suppression was stable and in most cases improving after transition. The researchers attribute the improvements to better ART with fewer adverse effects.

Significantly more dual eligible patients relied on ADAP, but the increase was gradual rather than abrupt.

The researchers concluded that this information has implications for all privatized, market-based prescription drug plans. It shows that transitions from one insurance structure to another can have significant implications for patients and also points to ADAP as an important safety net for those with HIV.


Belenky N, Pence BW, Cole SR, et al. Associations between Medicare Part D and out-of-pocket spending, HIV viral load, adherence, and ADAP use in dual eligibles with HIV. Med Care.2018;56(1):47-53. doi: 10.1097/MLR.0000000000000843.

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