Medicare Eligible Research Articles

Influence of prescription monitoring programs on analgesic utilization by an insured retiree population

To estimate the association between prescription drug monitoring programs (PDMP) and the probability of analgesic use, overall and by analgesic type. This cross-sectional study used 2007 Coordination of Benefits (COB) MarketScan administrative claims data of Medicare eligible and their dependents (n = 2 175 012). The exposure was PDMP status: no PDMP, electronic-only PDMP (ePDMP), or electronic + paper PDMP (e + pPDMP). Outcomes included any analgesic use and, among users, analgesic use by schedule (CII, CIII, CIV, or CV-Rx). Multivariable logistic and multinomial regressions were used to estimate the associations of PDMP status with any analgesic use and schedule of analgesic, respectively, controlling for sociodemographic and clinical factors. There were 834 489 (38.4%) subjects who received at least one analgesic; of these, 28.9% received one or more opioid analgesics (OAs). Compared to individuals in non-PDMP states, those living in PDMP states had increased odds of receiving any analgesic (OR(ePDMP) = 1.19, 99%CI = 1.19, 1.20; OR(e+pPDMP) = 1.04, 99%CI = 1.03, 1.05). Among analgesic users, the odds of receiving potent CII analgesics relative to CV-Rx analgesics were lowest for individuals residing in e + pPDMP states (OR(e+pPDMP) = 0.54, 99%CI = 0.53, 0.55), followed by ePDMP states (OR(ePDMP) = 0.76, 99%CI = 0.75, 0.77) relative to non-PDMP states. The odds of receiving CIII OAs were highest for individuals in PDMP compared to non-PDMP states. PDMPs are associated with reductions in utilization of targeted prescription OAs and increases in less scrutinized, lower scheduled OAs. Longitudinal studies are needed to determine how PDMPs shift analgesic prescribing and whether such shifts influence clinical care and economic outcomes.

Election 2008: Projecting the Winners

It's December and virtually all the votes have been counted (in some cases, recounted) to determine the outcome of this excruciatingly long election cycle. Barack Obama will be sworn in as the 44th President of the United States on January 20, 2009. Given the state of the world economy, he faces challenges of unprecedented size and shape. So what is the point about projecting the winners? Despite – or perhaps more accurately because of -- the collapse of the financial system, 2 wars, and rising unemployment, leaders in the Obama administration and in Congress have signaled their intent to tackle the $2 trillion dollar health care system as a leading priority for reform. The facts that over 50 million people are uninsured or underinsured and that much care is rendered in an uncoordinated and sometimes harmful manner are key drivers for change. The real driver, however, is the reality that in 2011 the first Baby Boomers turn 65 and become Medicare eligible. Projections are that without reform the system collapses or becomes totally unaffordable in just a few years. So who will win in this reformation that touches the lives of every single citizen of our country? I say it is those that come to the table with real solutions to a more efficient and rational health delivery and financing model. The vested interests are many and they are big and powerful. Hospitals, insurers, pharmaceutical companies, and physicians are those with the largest financial interest in our current delivery system. They have formidable lobbying power that quite frankly overshadows just about any lobbying resources the entire enterprise of pharmacy can muster. The current fiscal crisis has the potential to challenge the traditional imbalance of special interest power. A new set of arguments need to be made for health system reform that aligns incentives for the design and delivery of health care services that make more sense than those currently in play. We must begin with a fundamental shift in our thinking and design a model of care that is truly patient-centered (not hospital or physician centric). There must be a focus on prevention with serious incentives for patients to take action to prevent disease or modify the progression of illness. There must be more effective coordination of care delivered by teams of clinicians who share information, attend to evidence-based guidelines, and measure their performance against meaningful standards. There must be better decision making around rational care at the end of life. Academic pharmacy has much to bring to the table in these discussions. We have created and contribute daily to models of care for prevention and indigent, acute, and intensive care. We have evidence through our scholarship that when a pharmacist's services are part of a functional team, better patient outcomes are achieved. We have convinced our collaborating physicians that their practice is higher quality and safer for patients when they join forces with us to provide health services. We have economic analyses to demonstrate real savings in overall health care spending when pharmacists contribute their clinical savvy to the needs of patients. There will be pressures throughout the health reform discussions to seek the lowest prices for prescription drugs. Candidate Obama espoused support early in his election efforts for reimportation of drugs from outside the United States. His advisors have helped him realize that the risks for this may outweigh the benefits, but it signals his attention to the cost of drugs. We must help the Administration, including presumed Secretary of the Department of Health and Human Services Tom Daschle, and leaders in the House and Senate, see beyond getting drugs cheaper. The solutions we can bring to the table are much more powerful. So gather your evidence that the care we provide in our clinics, hospital units, and community pharmacies makes a difference. Commit to sharing that information with your members of Congress and their health policy advisory staff at home and, yes, even in DC. If we don't do so now, while the microscope is focused once more on the need for change in our broken health care system, someone else will bring solutions and pharmacists might not be in their picture of better health care.

Risk of hospitalizations/emergency department visits and treatment costs associated with initial maintenance therapy using fluticasone propionate 500 µg/salmeterol 50 µg compared with ipratropium for chronic obstructive pulmonary disease in older adults

Background: Cost-effective treatments for chronic obstructive pulmonary disease (COPD) are needed to reduce the burden on the Medicare system. Objectives: The objectives of this retrospective study were to compare the effects of fluticasone propionate 500 µg/salmeterol 50 µg (FSC 500/50) with those of ipratropium (IPR) in older adult patients with COPD on the following factors: (1) the risk of all-cause and COPD-related hospitalization and emergency department (ED) visits; and (2) all-cause and COPD-related treatment costs. Methods: This retrospective, observational cohort study assessed commercially insured patients aged ≥65 years (Medicare eligible) with COPD-related medical costs ( International Classification of Diseases, Ninth Revision, Clinical Modification codes 490.xx, 491.xx, 492.xx, or 496.xx), 18 months of continuous enrollment (12 months' pre-study and 6 months' poststudy), and ≥1 prescription claim (ie, the index event) for FSC 500/50 or IPR between January 2, 2001, and August 12, 2003. Exacerbation events (hospitalizations/ED visits) were assessed using Cox proportional hazards regression models controlling for baseline factors and preindex events. Treatment costs were estimated using multivariate generalized linear models to adjust for baseline characteristics and preindex utilization and costs. A propensity-matched comparison was conducted as a sensitivity analysis. Results: A total of 1051 patients (540 women, 511 men) were identified: 952 in the IPR group (mean age, 74.26 years) and 99 in the FSC 500/50 group (mean age, 72.38 years). Treatment with FSC 500/50 was not associated with a reduction in the risk of all-cause hospitalization or ED visit compared with IPR (adjusted hazards ratio [HR], 0.913 [95% CI, 0.673-1.238]); however, FSC 500/50 was associated with a significantly lower risk (45%) of a COPD-related event (adjusted HR, 0.547 [95% CI, 0.301-0.995]). Although treatment with FSC 500/50 was associated with significantly lower annual mean all-cause medical costs compared with IPR ($18,642 vs $25,556, P < 0.05), the use of FSC 500/50 was also associated with significantly higher annual all-cause pharmacy costs ($2813 vs $2244, P < 0.05). Compared with the IPR cohort, the FSC 500/50 cohort had lower mean annual COPD-related medical costs (-$464 [ P = NS]) and higher COPD-related pharmacy costs ($260 [ P < 0.01]). However, increased pharmacy costs may be compensated for by decreased medical costs in both all-cause and COPD-related services. Results from the sensitivity analysis with the propensity score-matched sample of 194 patients were similar. Conclusions: Compared with the IPR cohort, the FSC 500/50 cohort was 45% less likely to have a COPD-related exacerbation event and had similar medical costs. FSC 500/50 was a more effective initial maintenance therapy than IPR for this Medicare population, and, despite the $260 increase in COPD-related pharmacy costs, there was no significant difference in COPD-related medical costs.

Implementing the Medicare drug benefit in a diverse inner-city community

An integrated effort to maintain continued access to pharmacy services and prescribed medications for patients in an inner-city community before and during the implementation of the Medicare prescription drug benefit is described. An academic medical center and college of pharmacy in a culturally diverse, inner-city Chicago community created a strategy to provide uninterrupted pharmacy services to all of their Medicare Part D eligible patients, particularly those dual eligible for Medicaid and Medicare, during the transition from Medicaid to Medicare Part D, effective January 1, 2006. The percentage of dual-eligible patients in the Medicare Part D eligible population at the institution was more than twice the national average. A task force was created to prepare for the onset of Medicare Part D. The task force had goals in three areas: education, outreach, and operations; it was also responsible for the development of a contingency plan for any problems that could happen after January 1. A Medicare drug benefit consult service was formed to ensure that Medicare eligible patients understood the Medicare drug benefit and received customized assistance. Although problems were encountered, the investment in the preparation and implementation of the Medicare drug benefit, especially the consult service, resulted in a positive return on the institution's investment. Suggestions for other institutions facing the challenge of the implementation of the Medicare drug benefit are provided. Implementing a federal-level program among a diverse subset of patients is challenging and requires concerted efforts from health care providers and support from the institution. The Medicare drug benefit task force at the institution assumed responsibility for all pharmacy activities related to Medicare Part D and achieved its goals in education, outreach, and operations. This resulted in continued access to pharmacy services and prescribed medications for patients.

The economic burden of Barrett's esophagus in a Medicaid population.

To estimate the overall healthcare expenditures of patients with Barrett's esophagus in the West Virginia Medicaid population. West Virginia Medicaid-paid claims data for the period January 1, 1995, to December 31, 1999, were used for the study. The population included all individuals eligible for West Virginia Medicaid during the study period except for Medicare eligible- and Medicaid managed-care recipients. A prevalence-based approach was used to determine the cost of illness for Barrett's esophagus. The total cost of illness for Barrett's esophagus more than tripled, from $182399 in 1995 to $623864 in 1999, with approximately a 4(1/2)-fold increase in medical and more than a threefold increase in pharmacy costs. The average cost of treating Barrett's esophagus was found to be approximately $1207 per patient in 1999. Overall, pharmacy costs accounted for >66% of the total costs. Controlling for age, gender, and number of comorbidities, patients with Barrett's esophagus incur 21.2% higher overall costs than patients with gastroesophageal reflux disease and 62.4% higher overall costs than the general Medicaid population. The increasing prevalence of and resource utilization for Barrett's esophagus provide a framework for further analysis and implementation of policies aimed at appropriate allocation of resources for the state's Medicaid program.

Factors affecting total hospital charges and utilization for South Carolina inpatients with HIV/AIDS in 1994-1996,.

This study's analysis addresses trends in hospital utilization and costs for patients with human immunodeficiency virus acquired immunodeficiency syndrome (HIV/AIDS) from 1994 through 1996 in South Carolina, as well as the effect of patient sociodemographics, referrals, and provider characteristics. This is a population-based study of all emergency department visits and hospitalizations occurring during that time period. The total hospital charge per patient significantly increases over time, while the total inpatient days per patient decreases significantly, and the charge per day increases significantly. The proportion of patients with public insurance or who are indigent is increasing, and the proportion of those with private insurance is decreasing. Other variables that have a significant impact on total hospital charges, total inpatient days, and charges per day are types of insurance, physicians specialty, discharge status, and number of diagnoses (severity). Persons who are Medicare eligible are sicker and have higher hospital costs and more inpatient days when compared to those with Medicaid. Intensity of services (hospital charges per day) is associated with private insurance and self-pay patients. Persons with terminal illness stay longer and have higher costs. When HIV/AIDS is the primary admitting diagnosis, there are higher hospitalization costs. Increasing severity of illness (number of diagnoses) leads to higher total hospital charges and days. With the introduction of new AIDS treatments in 1996, further study is required to determine the effects of new drugs, physician specialties, and other provider characteristics on the cost and utilization of health care services, both inpatient and outpatient.

Is travel distance a barrier to veterans' use of VA hospitals for medical surgical care?

Lengthy travel distances may explain why relatively few veterans in the United States use VA hospitals for inpatient medical/surgical care. We used two approaches to distinguish the effect of distance on VA use from other factors such as access to alternatives and veterans' characteristics. The first approach describes how disparities in travel distance to the VA are related to other characteristics of geographic areas. The second approach involved a multivariate analysis of VA use in postal zip code areas (ZCAs). We used several sources of data to estimate the number of veterans who had priority access to the VA so that use rates could be estimated. Access to hospitals was characterized by estimated travel distance to inpatient providers that typically serve each ZCA. The results demonstrate that travel distance to the VA is variable, with veterans in rural areas traveling much farther for VA care than veterans in areas of high population density. However, Medicare recipients also travel farther in areas of low population density. In some areas veterans must travel lengthy distances for VA care because VA hospitals which were built over the past few decades are not located close to areas in which veterans reside in the 1990s. The disparities in travel distance suggest inequitable access to the VA. Use of the VA decreases with increases in travel distance only up to about 15 miles, after which use is relatively insensitive to further increases in distance. The multivariate analyses indicate that those over 65 are less sensitive to distance than younger veterans, even though those over 65 are Medicare eligible and therefore have inexpensive access to alternatives. The results suggest that proximity to a VA hospital is only one of many factors determining VA use. Further research is indicated to develop an appropriate response to the needs of the small but apparently dedicated group of VA users who are traveling very long distances to obtain VA care.

A method for adjusting capitation payments to managed care plans using multivariate patterns of health and functioning: the experience of Social/Health Maintenance Organizations.

A multivariate procedure for identifying case-mix dimensions from discrete health variables is presented. Since the dimensions are generated only from health use data and not service use data, they can be used for adjust capitation rates to provide incentives to treat persons not currently well integrated in standard health care system (e.g., very ill persons, the uninsured) or to promote specific health outcomes. The procedure is illustrated with data from Social/Health Maintenance Organizations (S/HMO) since they provide both acute and long-term care (LTC) services. Thus, case-mix measures to adjust S/HMO reimbursements have to represent both medical conditions and the degree, and type, of functional impairment. From 31 health and functioning items, six case-mix dimensions, and scores for individuals on each, were calculated. The multivariate distribution of scores in S/HMO enrollees, and in Medicare eligible, comparison samples, were examined in each site to see how their health differed. S/HMO enrollees were healthier and less frail than persons remaining in the Medicare FFS system. Such differences are important in adjusting capitation rates to provide incentive to accept clients with complex health problems.