Impact of a Pharmacy Care Management Service on Medically Complex Medicare Advantage Members

Abstract

Summary Medicare Advantage (MA) programs have grown rapidly, and a shift toward more medically complex beneficiaries has implications for health care utilization, costs, and quality in the MA program. Ensuring safe and effective medication use in this population has been identified as a priority, yet there is limited evidence to guide MA plans’ pharmacy care management (PCM) efforts. The goal of this study was to investigate the impact of an integrated PCM program for MA beneficiaries taking multiple chronic medications, including a subset with high predicted cost savings from improved medication adherence, assessed using the Value of Future Adherence (VFA) score. Using adjudicated administrative claims data from a regional Medicare Advantage and Part D (MAPD) plan, a retrospective matched cohort study was designed. A total of 724 members receiving PCM services were matched to 3,620 control members who received usual pharmacy care. From these two cohorts, 196 of 724 PCM participant members and 980 of 3,620 control group members were defined as having a high VFA score. PCM program enrollees underwent monthly medication reviews, reconciliation, and synchronization of refills, which were dispensed and delivered to the home in adherence packaging by a specially equipped pharmacy. Members were contacted monthly and received, as needed, education, referral to health care providers, consultation with prescribers on changes to medication regimens, and referral to social support or case management programs. Primary outcomes of interest were per enrollee per month (PEPM) costs, resource utilization, and medication adherence for three MAPD Star Ratings measures — Medication Adherence for Diabetes Medications, Medication Adherence for Hypertension (renin-angiotensin system antagonists [RASAs]), and Medication Adherence for Cholesterol (statins) — over 12 months for all members and for the subgroup with a high VFA score. The authors found that among all PCM program enrollees, there was a $50 (95% confidence interval [CI], $15 to $86; P = 0.005) PEPM increase in average pharmacy spending compared with control members and an offsetting $158 (95% CI, −$265 to −$51; P = 0.004) PEPM decrease in medical spending, resulting in PCM participants having $108 (95% CI, −$221 to $5; P = 0.062) lower PEPM total cost of care. Compared with the control group, PCM enrollees had 15% (P = 0.008) fewer inpatient stays and improvements in medication adherence of 7.3% among members taking oral antidiabetic agents, 9.4% among members taking statins, and 12.9% among members taking RASA antihypertensive agents (P < .001 for all three measures). These effects were driven by the patients in the subgroup with a high VFA score, for whom PEPM total cost of care was $406 (95% CI, −$645 to −$161; P < 0.001) lower than control members. These findings support the potential value of an integrated PCM program for MAPD beneficiaries on multiple medications, particularly when targeted to those members predicted to benefit most.