Impacts of HPI on US Health Policies

HPI faculty have established a strong record of national and international leadership in the evaluation of health policy changes in chronically ill populations, particularly insurance coverage for medications on use of essential medication, affordability of medication, and clinical outcomes. These studies, combined with HPI faculty testimony, advice, and major op-eds have had substantial impacts on worldwide healthcare policies in both the public and private sectors.

 

Effects of drug reimbursement limits in Medicaid

Our initial landmark studies examined the effect of caps placed on the prescription drug benefit for low income elderly and disabled individuals in New Hampshire Medicaid.  This policy change reduced the use of nonessential drugs, but also had the unintended effect of causing a substantial decline in the use of essential medications, and it doubled the risk of permanent institutionalization in nursing homes.  Similarly, such limits also reduced use of effective antipsychotic medications and increased the use of acute care for patients with schizophrenia, at a cost 17 times higher than the savings from reduced drug utilization.

 

These research findings have been used by many states when deciding to reject strict limits on drug coverage for vulnerable populations and to expand state-funded pharmacy assistance programs.  Congress, the Department of Health and Human Services, the White House and patient care advocates have used this work to argue successfully for subsidies to the drug coverage under Medicare Part D (initiated in 2006) for low income individuals.  HPI faculty have testified before the House Appropriations Committee calling for this coverage policy.

 

The National Alliance for the Mentally Ill (NAMI) and AARP  (formerly known as the American Association of Retired Persons), in written statements to the Agency for Health Care Research and Quality, said that HPI’s “landmark” studies (funded by NIMH and AHRQ) helped to increase nationwide access to essential medications among the chronically ill, elderly, and mentally ill.  NAMI used the studies in a national program to support states on medication access, improvement of prescribing practices as an alternative to cost-containment policies, grievance procedures, health care reform, and increased funding for NIMH on access to new medications.  AARP used HPI research to expand prescription drug coverage for low income people in six states before enactment of Medicare Part D. The Commissioner of the Massachusetts Department of Mental Health also used this research to ensure access to a wide range of antipsychotic medications in that State.

 

Based in large part on these HPI studies, the Government of Australia rejected proposed drug benefit limits, and Quebec (Canada) agreed to reverse a province-wide high-deductible medication plan for welfare patients. 

 

HPI faculty have served as expert witnesses in two federal court suits by AARP that resulted in exemptions of individuals with specific chronic illnesses from a drug prescription cap in Tennessee, and at state level, worked closely with the Massachusetts Health Care Reform Connector Board to ensure prescription drug coverage and affordable cost sharing as part of its recently-implemented universal health insurance program. 

 

PPI Advocacy to Insure Drug Coverage as part of Massachusetts Health Reform

HPI faculty worked closely with the Massachusetts Health Care Reform Connector Board to ensure prescription drug coverage and affordable cost sharing as part of its recently-implemented universal health insurance program. 

 

Dr. Soumerai testified before the State Legislature, spoke at press conferences, was an expert witness at The Health Care Reform Connector Board  (that leads the coverage program), and published an influential op-ed in the Boston Globe (“Prescription drug coverage should not be optional”) two days before the vote to insure coverage of medications in all health reform plans, not just those serving the elderly and sick. Health Care for All wrote that these efforts were key to the successful effort to provide consistent coverage despite significant opposition to the policy.

 

HPI Analyses Promoting Coverage of Essential Medications in Medicare Part D

HPI studies were used exclusively in legislation crafted by the American Psychiatric Association and Congress to (belatedly) allow coverage of appropriate use of benzodiazepines and barbiturates in the Medicare Part D drug benefit.

 

Measures of Cost-Related Nonadherence

In 2004, just ahead of Part D implementation, CMS incorporated HPI’s measures of cost-related medication nonadherence into its major, routine national survey of Medicare beneficiaries in order to evaluate the new drug benefit and to monitor economic access to medications among vulnerable populations over time.  The Obama Administration referred to these measures of economic access to medications in its efforts to expand insurance coverage to low income populations. The government of Canada has since adopted HPI’s measures of cost-related nonadherance for routine collection throughout Canada.   

 

National and International Quality Improvement Activities

HPI faculty co-developed, in multi-state randomized trials, a physician face-to-face medication quality improvement method, “academic detailing”, that has been adopted by several countries’ universal health plans, by Medicaid programs in the US, and by numerous private health plans.  They also advised several federal agencies and Congress on the benefits and risks of mandating drug utilization review; Congress subsequently enacted legislation requiring “education outreach” efforts including academic detailing in all 50 states, quoting heavily from HPI publications.  Based in part on our published AMI Guideline Implementation “opinion leader” experiment, the Department of Health and Human Services (DHHS conducted a similar program in all 50 states.

 

Other Impacts of HPI Research on Health Policy

  • In the 1990s the Governor of Illinois proposed to eliminate drug coverage in Medicaid as a stopgap “cost saving measure” unless evidence could be found that such a step would hurt patients and raise health care costs.  A rapid national search by state policy staff led to HPI work on the unintended costs of drug payment limitations that convinced the policy makers to abandon their legislative proposal because it could raise costs by damaging the health of Medicaid enrollees.
  •  HPI recommendations and published data were important contributing factors in the decisions by the states of California, New York, Florida, Georgia, and several other states to reject severe drug payment caps and to promulgate safer cost-containment measures (e.g. mild cost-sharing).
  • Vermont’s initial health care plan included pharmaceutical coverage for near-poor elderly based primarily on the likelihood that this would reduce expensive nursing home admissions, a conclusion drawn from HPI studies on the impact of drug coverage limits on nursing home admissions among Medicaid elderly.
  • Based on HPI faculty’s 2010 Boston Globe op-ed documenting state censorship of health policy research fellows’ studies using Massachusetts health care data, the Secretary of the Massachusetts Department of Health and Human Services sought our policy advice, and set up legal safeguards to protect academic freedom. 
  • HPI studies led directly to new CMS and HEDIS measures that successfully increased beta blocker use and reduced mortality following acute MI in the elderly
  • HPI faculty published a 2012 landmark op-ed in the Wall Street Journal debunking the assumption that the roll-out of electronic health records to all medical providers in the US would save medical care costs. The leading IT journal (IEEE Spectrum) in the world and other outlets called it the beginning of a major backlash against HITECH (mandated by the 2008 stimulus legislation) that has continued until today.

A HPI study resulted in the cessation of an ineffective commercial insurance program (at Harvard Pilgrim Health Care) to encourage adherence to depression treatment.