Abstract
Background: For Medicare Part D beneficiaries, drug costs after reaching the drug benefit threshold (DBT) could contribute to non-adherence and adverse outcomes. Because beneficiaries who reach the DBT might take prescriptions (Rx) to pharmacies that offer low-priced generic drugs, there is potential for loss of integrated care, as those pharmacies may not be affiliated with beneficiaries’ health plans. Potential implications of Rx dispensing external to members’ health plans include drug interactions, adverse events, lack of monitoring, and inaccurate adherence data. We sought to examine the extent to which Medicare beneficiaries take Rx outside a health plan and to describe those patients. We hypothesized that beneficiaries who reach the DBT are more likely than those who do not reach the DBT to have Rx dispensed at external pharmacies. Methods: This retrospective study included all Kaiser Permanente Colorado (KPCO) Medicare beneficiaries with membership in 2006 and 2007 (n=37,092). Data collected from electronic databases included demographics, membership, benefit structure, and comorbidities (Quan comorbidity index, QCI). A random sample of electronic medical records (n=100) was abstracted for information not available from administrative data. Chi-square and Wilcoxon Rank Sum tests were used to compare beneficiaries. Results: Among 27,354 beneficiaries who had a DBT, 1,655 (6%) took Rx to external pharmacies in 2007. Of 1,785 beneficiaries who reached the DBT, 12.4% (n=222) had external Rx compared to 5.6% (n=1433) of 25,569 who did not reach the DBT (P<0.001). Of those who reached the DBT, beneficiaries with external Rx had more comorbidity (external Rx mean QCI 4.2 [±2.8]; no external Rx mean QCI 2.4 [±2.1]; P<0.001). Chart review determined that not all Rx written externally were filled at pharmacies offering low price Rx: only 14% were documented taken to pharmacies advertising low price Rx, while 16%, 21%, and 43% were documented taken to military pharmacies, hospice/ nursing homes, or no dispensing location, respectively. Additionally, 11% of external Rx were nonformulary drugs. Subsequent prescriptions for 20% of all external Rx were dispensed at KPCO pharmacies. Conclusions: KPCO Medicare beneficiaries who reached the DBT more often had Rx dispensed externally. Of those who reached the DBT, beneficiaries with external Rx had more chronic illnesses. Clinical consequences of Rx dispensed outside integrated health plans require further study.
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