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From Dunkin Donuts…. To Krispy Kreme: Making a Bigger, Better Donut Hole

From Dunkin Donuts…. To Krispy Kreme: Making a Bigger, Better Donut Hole. Group IV. National Mental Health Association, May 2005. Problem Statement. Structure of cost sharing under Part D negatively impacts quality Dimensions of the problem Vulnerable beneficiaries most affected

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From Dunkin Donuts…. To Krispy Kreme: Making a Bigger, Better Donut Hole

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  1. From Dunkin Donuts….To Krispy Kreme:Making a Bigger, Better Donut Hole Group IV

  2. National Mental Health Association, May 2005

  3. Problem Statement • Structure of cost sharing under Part D negatively impacts quality • Dimensions of the problem • Vulnerable beneficiaries most affected • Patients less likely to fill prescriptions • Providers may not provide access to most effective drugs • Alternatively presents a moral hazard

  4. Rationale • Experience with Part D • 25% of beneficiaries will experience higher costs • 6.9 million projected to reach coverage gap • 3.1 million will reach catastrophic coverage • Near-poor (LIS-eligible) less likely to enroll • Duals confront copays for first time • Premiums lower and coverage better than projected

  5. Rationale • Impact on Quality • Cost-related Adherence • Uninsured 2.5 times more likely not to fill prescription • 16.4% of Medicare recipients did not fill scripts • 15.2% of insured did not fill scripts

  6. Rationale • Impact on Quality • Prescribing practices • Shoot-the-Moon • Under-prescribing

  7. Stakeholders (1) • Who will support this plan? • Seniors • Disease-specific interest groups • Who will oppose it? • Seniors with other credible coverage • Seniors without targeted chronic diseases • Other disease-specific interest groups • Working population paying Medicare tax

  8. Stakeholders (2) • Other Supporting Stakeholders • Health care providers • AARP • PhRMA • Pharmaceutical companies • Capitated health care systems • Fiscal conservatives

  9. Stakeholders (2) • Other Opposing Stakeholders • Some specialty health care providers • Some pharmaceutical companies • Fee-for-service health systems • Pharmacies

  10. Plan of Action • Minimizing complications resulting from problematic access to drugs • Preserving cost; Improving quality

  11. Plan of Action High complication chronic diseases • Highest evidence standards • Long-term cost savings for Medicare • Documented evidence of (examples): • Diabetes • Hypertension • Congestive Heart Failure • Establish independent advisory group

  12. Plan of Action

  13. Plan of Action Expand the Donut Hole

  14. Plan of Action High complication chronic diseases • Highest evidence standards • Long-term cost savings for Medicare • Documented evidence of (examples): • Diabetes • Hypertension • Congestive Heart Failure • Establish independent advisory group

  15. Plan of Action • Financing Campaign • Disease-specific interest groups • PhARMA • Capitated health systems • Budget Impact • Initial administrative component • Cost-neutral over 5 years • Cost-saving over 10 years to Medicare

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