Roles of community helpers in using the Medicare Part D benefit

The passage of the Medicare Modernization Act in 2003 brought a prescription drug benefit to the Medicare program for the first time, which has been a boon for many beneficiaries. However, Part D, as this prescription drug benefit is called, has come with some new access and information challenges. Unlike Medicare Parts A and B, the Medicare Part D benefit is administered through a variety of private insurance plans, with formularies and pharmacy networks that can vary greatly from one plan to the next1. When the Medicare prescription drug benefit took effect in 2006, advocates for Medicare beneficiaries predicted that the switching of seven million dually-eligible beneficiaries (i.e., those with both Medicare and Medicaid benefits) from Medicaid prescription programs to the Medicare Part D benefit would result in chaos and discontinuities in access to prescription medications for many beneficiaries2. The reality of what has happened with the implementation of Part D is more complicated, and in some ways, more hopeful. Dually-eligible beneficiaries have, for the most part, been able to maintain continuous medication coverage and avoid problems with access to medicines3. The Medicare Part D benefit provides much assistance to adults with mental illness and has become a major source of funding for psychiatric medications4. For most service users, the transition from Medicaid benefits to the Medicare prescription drug program has gone fairly smoothly3. This continuity of care has occurred because many Part D beneficiaries have connections to community professionals and family members who have helped them to understand the program and take advantage of their benefits. In particular, beneficiaries with serious mental illness have received much assistance and critically-needed information from community helpers in using their Medicare prescription drug insurance. The ease of the transition has been greatly affected by the involvement of local pharmacists, nurses, and community mental health case managers (also called community support workers), in addition to family members, in the Part D process5,6. Literature review The existing literature on Part D and adults with mental illness relies primarily on reports from psychiatrists on their patients. These studies, conducted by the American Psychiatric Association’s (APA) Research Institute, provide an important look at the Part D program and its effect on dually-eligible beneficiaries with mental illness7–10. Psychiatrists have reported disruptions in access to medicine among dually-eligible beneficiaries, resulting in a troubling number of interactions with crisis services and inpatient hospitalizations7. Over 40 per cent of the dually-eligible patients reported on by their psychiatrists in these studies had experienced a medication access problem since the implementation of Part D. Most of the other quantitative studies of Medicare Part D have focused on enrollment and access among older adults. Besides studies using pharmacy claims data and data from the Centers for Medicare and Medicaid Services, there have been a few qualitative explorations of the impact of the Medicare prescription drug benefit from the perspective of beneficiaries. Most of the qualitative studies have been conducted by the Kaiser Family Foundation and its Commission on Medicaid and the Uninsured5,11–15. Perry, Kitchman and Guyer12 conducted a study of dually-eligible beneficiaries to understand more about their opinions regarding the soon-to-be-implemented Medicare Part D program. After conducting five focus groups, one of which consisted of dually-eligible beneficiaries with mental health needs, the authors found that dually-eligible beneficiaries were frequent users of prescription medicines, and that many of these beneficiaries feared that the Medicare Part D benefit would worsen rather than improve their access to their medicines. During the implementation of Part D, the “Voices of Beneficiaries” project of the Kaiser Family Foundation conducted a series of in-depth interviews with beneficiaries, some of whom were dually-eligible for Medicare and Medicaid, and several of whom were diagnosed with a mental illness. Results from this project determined that most beneficiaries appeared satisfied with their Part D benefits, although there was some confusion regarding plan information and plan enrollment. Interestingly, the “Voices of Beneficiaries” reports also mentioned the important role of pharmacists and other community helpers in assisting Part D participants with choosing Part D plans, interpreting their benefits, and obtaining medications11,13–15. Buchsbaum et al.5, in a study sponsored by the Kaiser Commission on Medicaid and the Uninsured, interviewed key informants by telephone regarding their opinions and experiences with the Part D benefit. These key informants comprised health care professionals, social service professionals, advocates, and community leaders who had experience with the Part D program. They tended to be much more negative about the Medicare prescription drug program than beneficiaries themselves. In addition, they provided extensive narratives regarding the assistance that they had provided to vulnerable low-income and disabled beneficiaries in using and understanding their prescription drug coverage. There has been one other qualitative study of the implementation of the Part D program, a study conducted for the Medicare Payment Advisory Commission by the National Opinion Research Center (NORC) at the University of Chicago and Georgetown University16. In this study, group interviews were conducted of physicians, pharmacists, and beneficiaries regarding their early experiences with the Part D benefit. The findings are not specific to beneficiaries with mental illness and are more focused on the experiences of the elderly with the Part D program. Many of the professionals interviewed in this study expressed dissatisfaction with Part D, but most beneficiaries reported being quite satisfied with their Part D plans. In summary, the existing literature on Medicare Part D from the perspective of beneficiaries is quite limited, and the specific experiences of Medicare beneficiaries with mental illness have not been adequately explored. Greater understanding is needed of the Medicaid-to-Medicare transition, as well as continuing experiences with Part D over time. Adults with mental illness who receive Medicare benefits are younger and have lower incomes than the typical older adult Medicare beneficiary17. These differences need to be considered and explored, as they may affect the use of cost-sharing strategies associated with Part D, the use of medication therapy management and community-based service coordination, and beneficiaries’ access to prescription medications. This article shares results from a larger qualitative study on the perspectives and opinions of Medicare Part D beneficiaries with mental illness. Specifically, this paper uses focused ethnography to report on the experiences and opinions of 26 Medicare beneficiaries with severe mental illness from a Midwestern urban area. In addition, this paper discusses the assistance provided to these beneficiaries by pharmacists, nurses, community support workers, and family members in the use of the Medicare prescription drug benefit.