Healthcare utilization varies among Medicare beneficiaries across different income levels. This variation exists in Part D, even though many Medicare beneficiaries with limited income receive help paying their Part D premiums and cost-sharing through LIS.

Avalere analyzed how often brand-name prescription drug fills in selected therapeutic areas are prescribed by specialists versus primary care providers and variation by beneficiary LIS status. For brand-name drugs in all 4 therapeutic areas included in the analysis, a smaller share of claims was prescribed by a specialist for LIS beneficiaries than for non-LIS beneficiaries.

Source: Avalere analysis of 2019 Part D Drug Event data

Some of the conditions treated by the drugs in these therapeutic areas may not necessitate specialist care. Even so, differences in prescribing patterns for prescription fills in these therapeutic areas between LIS and non-LIS patients may point to underlying differences in the care patterns of different patients. Given these existing differences in treatment patterns between LIS and non-LIS beneficiaries, stakeholders considering the impact of reforms to Part D should consider how proposals impact different segments of the Medicare population.

Methodology

Avalere used a randomly selected sample of 2019 Medicare Part D Drug Event data representing 20% of the Medicare market under a research-focused data use agreement with the Centers for Medicare and Medicaid Services. Avalere identified prescription drug claims for products in the 4 therapeutic areas based on 2- or 4-digit Generic Product Identifier codes from the Medispan database based on the National Drug Code on the claim. Avalere then identified whether each claim was for a brand or generic drug using the Medispan database.

Next, Avalere matched each prescription drug claim to the prescriber’s primary taxonomy using the Prescriber Characteristics File. Avalere placed provider taxonomies into 4 prescriber types: primary care, specialist, other professional, and facility. Only physicians (78% of brand scripts in these therapeutic areas), physician assistants (5%), and nurse practitioners (13%) are categorized as primary care or specialists. The remaining 4% of brand scripts in these therapeutic areas were prescribed by other providers, including facilities or other professional providers. Avalere then summarized utilization based on the prescriber type and the beneficiary LIS status.

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