Posted by Phillipa on August 31, 2012, at 21:03:45
I do know that benzos are not paid for by my Medicaire. But I do know that I take low doses and look what now has been discovered about benzos. Keep dose low no problems. Phillipa
From Medscape Medical News > PsychiatryMedicare Part D Exclusion Changes Anxiety Treatment
Deborah Brauser
Authors and Disclosures
August 31, 2012 The Medicare Part D coverage exclusion for benzodiazepines (benzos), which went into effect in 2006, has had a huge effect on treating elderly patients with anxiety disorders, new research suggests.
A cohort study of more than 10,000 enrollees in healthcare plans showed that use of nonbenzodiazepine medications significantly increased for patients diagnosed with an anxiety disorder after the exclusion went into effect, "without substitution of increased behavioral care."
"The findings suggest that these patients didn't benefit from having the exclusion," lead author Michael K. Ong, MD, PhD, from the Department of Medicine at the University of California, Los Angeles, told Medscape Medical News." While there didn't seem to be any clinical effects on a population basis, these patients did end up having to pay more money out of pocket."
Dr. Michael Ong
Rationales for the exclusion's establishment include results from several studies showing that long-term use of the medications by elderly patients was associated with increased risk for falls, hip fractures, gait disturbance, and even cognitive impairment.
Although the Patient Protection and Affordable Care Act has now eliminated the Medicare Part D exclusion of benzodiazepines, that rule will not go into effect until 2013.
In addition, individual states may still try to keep some form of exclusion of the medication class in place. For example, the state auditor of California is recommending their exclusion from Medicaid coverage "in an effort to reduce budget costs," report the investigators.
"From a policy perspective, I think our study suggests that that shouldn't be the first thing on the list that people should be considering," said Dr. Ong.
The study was published in a recent issue of Psychiatric Services.First-Line Treatment
The Medicare Modernization Act (MMA) led to the provision of prescription drug coverage through Medicare Plan D starting in 2006, but it included the caveat that benzodiazepines be excluded.
"As a result, only patients with supplemental drug insurance through Medicaid or private secondary insurance, for example have access to benzodiazepine coverage," write the investigators.
"However, when used appropriately, benzodiazepines are an effective, low-cost treatment for anxiety. A major concern regarding the MMA's...exclusion was potential adverse effects on patients with anxiety disorders," they add.
The researchers note that few studies have assessed the exclusion's effects on patients overall, and none have examined the effect on those specifically with anxiety disorders, "the population most likely to be adversely affected by the policy's implementation."
The investigators examined records for 8397 people older than 64 years (mean age, 75.5 years; 79% women) enrolled in the Medicare Advantage Plan, which has the benzodiazepine exclusion, and 1657 people between the ages of 60 and 64 years (68.9% women) who had a different managed healthcare plan.
For this analysis, data on just the patients diagnosed with a new anxiety disorder in the first 6 months of 2005, 2006, or 2007 were assessed.
"If anybody was going to be affected by the exclusion, it would be these types of patients because benzodiazepines are a first-line treatment for anxiety disorders," said Dr. Ong.
Higher Costs, Reduced Treatment?
Results showed that the participants enrolled in the Medicare plan who were diagnosed with the disorder in 2005 had significantly higher rates of claims for benzodiazepines than Medicare enrollees diagnosed in 2006 or 2007 (63% vs 0.9% and 1.3%, respectively).
They also had significantly higher rates of claims for all psychotropic drugs (75.4% vs 45.9% and 50%, respectively), fewer claims for nonbenzodiazepines, and lower expenditures for all psychotropic medications.
"There were no significant differences over time in utilization or expenditures related to psychotropic medication among the comparison group," report the researchers.
In addition, no significant changes were found for either group in outpatient visits for behavioral care, or in hospital stays related to benzodiazepine withdrawal, or inappropriate use of the medications.
"The decline in covered claims for psychotropic medication following the implementation of the MMA may reflect an overall reduction in treatment of anxiety, given that we did not find evidence that outpatient behavioral care use had increased" as a substitute, write the investigators.
"Even if implementation of the MMA reduced inappropriate benzodiazepine use, any reductions achieved did not result in reduced hospitalizations or emergency department visits and were accompanied by slightly higher medication expenditures," they add.
Overall, the researchers note that although the exclusion may have improved care for Medicare enrollees who do not have anxiety disorders, those newly diagnosed with the disorders have faced higher costs and reduced treatment.
"These findings suggest that states seeking to reduce budget costs through restrictions of benzodiazepines may actually increase overall costs."
A "Slippery Slope"
However, Brent Forester, MD, director of the Geriatric Mood Disorders Research Program at McLean Hospital in Belmont, Massachusetts, and assistant professor of psychiatry at Harvard Medical School in Boston, has a different view on the role of these medications in an elderly population.
Dr. Brent Forester
Dr. Forester, who was not involved with this research, told Medscape Medical News that in his role as a geriatric psychiatrist, he has met with many people who have had complications from long-term use of benzodiazepines for anxiety, depression, or sleep disturbances.
"What was supposed to be a short-term treatment for insomnia or anxiety becomes a 3- or 4-year problem. They're presenting to our memory clinic with what appears to them as Alzheimer's disease; we do an evaluation and find out that they're on 2, 3, or 4 mg of a benzodiazepine; and then we spend the next 6 months or longer trying to get them off the medication, which is extraordinarily difficult," he reported.
"Lo and behold, often when they come off of the medication, they're walking better or they're no longer nearly as confused. So I come from the very biased standpoint of seeing all the adverse consequences of benzodiazepines in older adults, and think that the medications should only be used for a very short-term treatment, if at all."
Dr. Forester noted that these medications can help patients to feel calmer, "but they're not long-term solutions. And anxiety is a long-term problem."
"This study's hypothesis seemed to be that taking away this coverage was going to cause all sorts of problems in terms of the care of the patient. They found that people started substituting other psychiatric drugs for benzos. And my question is: how did that affect outcome? I don't think they really addressed that; they just looked at the immediate effect of the exclusion," he said.
He noted that mirtazapine might be a better solution for a patient who is having trouble with sleep or anxiety.
"It will also help stimulate appetite and act as an antidepressant. And it will much, much, much less likely be associated with gait disturbance and confusion," he said, adding that nonpharmacological treatments such as cognitive-behavioral psychotherapy are also effective.
Still, Dr. Forester said he is not a fan of wholesale exclusions of any type of medication, and that treatment decisions should be left to the prescriber.
"I wouldn't argue that excluding medications because of their side effects is a good thing to do. With the benzos, I can see what their rationale is for why they did it. But I wouldn't want it to become a slippery slope as they come up with other reasons to exclude other classes," he said.
"The reality is that many people take benzos and have taken them safely. But generally speaking, they don't tend to be older people who have been on them for 10 or 20 years like the people that I see. That's where we run into problems."
The study was supported by grants from the National Institute of Mental Health. Two of the study authors report several disclosures, which are listed in the original article. Dr. Ong, the other 2 study authors, and Dr. Forester have disclosed no relevant financial relationships.
Psychiatric Serv. 2012;63:637-642
poster:Phillipa
thread:1024589
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