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The American Journal of Managed Care May 2018
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Characteristics and Medication Use of Veterans in Medicare Advantage Plans
Talar W. Markossian, PhD, MPH; Katie J. Suda, PharmD, MS; Lauren Abderhalden, MS; Zhiping Huo, MS; Bridget M. Smith, PhD; and Kevin T. Stroupe, PhD
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Hsueh-Fen Chen, PhD; Adrienne Nevola, MPH; Tommy M. Bird, PhD; Saleema A. Karim, PhD; Michael E. Morris, PhD; Fei Wan, PhD; and J. Mick Tilford, PhD
Changes in Specialty Care Use and Leakage in Medicare Accountable Care Organizations
Michael L. Barnett, MD, MS, and J. Michael McWilliams, MD, PhD
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Carla V. Rodriguez, PhD; Kevin B. Rubenstein, MS; Benjamin Linas, MD; Haihong Hu, MS; and Michael Horberg, MD
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Olena Mazurenko, MD, PhD; Jay Shen, PhD; Guogen Shan, PhD; and Joseph Greenway, MPH
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Kim Ekblom, MD, PhD, and Annika Petersson, MSc, PhD

Characteristics and Medication Use of Veterans in Medicare Advantage Plans

Talar W. Markossian, PhD, MPH; Katie J. Suda, PharmD, MS; Lauren Abderhalden, MS; Zhiping Huo, MS; Bridget M. Smith, PhD; and Kevin T. Stroupe, PhD
Veterans enrolled in Medicare Advantage plans differed from fee-for-service sector enrollees in several demographic, geographic, and clinical characteristics and in patterns of medication use.

Objectives: To compare characteristics, health conditions, and medication acquisition patterns by fee-for-service (FFS) or Medicare Advantage (MA) plan enrollment status for Medicare-eligible veterans.

Study Design: Retrospective analysis of all female and a random 10% sample of male veterans.

Methods: Data were derived from the US Department of Veterans Affairs (VA) and Medicare administrative databases. Demographic, geographic, and RxRisk-V risk classes were ascertained in 2008. Medicare Part D enrollment, medication acquisition, and use of high-risk medications (HRMs) were examined in 2009. A veteran was classified as an MA enrollee if he or she was enrolled in an MA plan for at least 1 month in 2008-2009. Descriptive and regression analyses were conducted to compare veterans’ characteristics and medication acquisition patterns by plan enrollment type controlling for veterans’ characteristics.

Results: Veterans who resided in urban settings and in the West or Northeast and who had co-payments for their VA medications had greater odds of enrolling in MA programs compared with their counterparts. MA-enrolled veterans were more likely to be dual (32.3% vs 7.0%) or Medicare-reimbursed (31.1% vs 14.5%) pharmacy users and less likely to be VA-only pharmacy users (29.4% vs 48.7%) than FFS enrollees. Higher proportions of MA-enrolled veterans received HRMs compared with those in the FFS sector (17.0% vs 14.3%).

Conclusions: Providers both inside and outside of the VA should consider that substantial information about the medication use of veterans may be unavailable in their healthcare systems’ electronic records.

Am J Manag Care. 2018;24(5):247-255
Takeaway Points

We compared patient characteristics, health conditions, and medication acquisition patterns by fee-for-service (FFS) or Medicare Advantage (MA) plan enrollment status for Medicare-eligible veterans.
  • MA plan–enrolled veterans differed from FFS sector–enrolled veterans in several important demographic, geographic, and clinical characteristics, as well as in medication use patterns.
  • Higher proportions of MA plan–enrolled veterans were dual Medicare and US Department of Veterans Affairs (VA) pharmacy users and received high-risk medications compared with those enrolled in the FFS sector.
  • Providers both inside and outside of the VA caring for these veterans should consider that substantial medication information might be unavailable in their healthcare systems’ records.
The Medicare Advantage (MA) program, introduced in 1982, authorized Medicare to contract with private insurers to provide healthcare coverage for a monthly prospective per enrollee capitated payment. Typically, MA plans offered supplemental benefits, such as prescription drug coverage1,2 or lower out-of-pocket premiums,1-3 that exceeded the Medicare entitlement. Studies in age-eligible Medicare beneficiaries showed that beneficiaries who enrolled in MA plans had lower pre-enrollment expenditures, fewer health conditions, lower use of services, and lower postenrollment mortality compared with beneficiaries who remained in the fee-for-service (FFS) sector.4-6 Studies also showed that MA plans attracted a higher percentage of African American beneficiaries,7 Latino beneficiaries, and beneficiaries with low education and fewer financial resources.7 MA plans treated chronic conditions more aggressively once they were diagnosed8,9 and had fewer disparities in quality of care than the FFS sector.10 Veterans were more likely to enroll in MA plans if they were nonwhite, had better self-reported functioning, exercised, or did not smoke. However, veterans were also more likely to enroll if they consumed alcohol or had more health conditions.11

Many veterans who were dually enrolled in the US Department of Veterans Affairs (VA) healthcare system and in Medicare used both VA and Medicare healthcare.12 The VA is able to track healthcare use and diagnoses of veterans in the VA system and FFS Medicare facilities using diagnosis-based instruments (eg, diagnosis-related groups,13 Diagnostic Cost Groups,14 and Ambulatory Clinical Groups15). However, the VA is unable to track healthcare use or diagnoses at MA facilities because MA plans are not required by the federal government to submit encounter-level records. As a result, this data incompleteness underestimates the prevalence of comorbidities for MA-enrolled Medicare-eligible veterans. Therefore, many studies of healthcare and medication use in Medicare-eligible veterans have excluded veterans enrolled in MA plans from their analyses to avoid this measurement error,16-20 despite the growing numbers of MA-enrolled veterans. In 2011, MA-enrolled veterans represented 21% of all Medicare-eligible VA users.21

There are limited data from empirical evaluations of the choice between FFS versus MA plans in Medicare-eligible veterans. Also, no previous study has compared medication acquisition patterns, overlapping medications, and receipt of high-risk medications (HRMs) from VA and Part D–reimbursed pharmacies by plan enrollment type. With the implementation of Medicare Part D and availability of prescription data obtained from VA and Medicare Part D–reimbursed pharmacies, this study was able to adjust for comorbidities using a pharmacy-based case mix instrument and assess patient characteristics and health conditions associated with enrollment in an FFS or MA plan by Medicare-eligible veterans during 2008 and 2009. In addition, we examined medication acquisition patterns by MA plan enrollees compared with Medicare FFS enrollees.


Subject Selection

The sampling frame for this study consists of all women and a random 10% sample of men from the VA Vital Status file. The Vital Status file contains demographic information and dates of death of individuals who received VA care, were enrolled in the VA system, or received VA compensation or pension benefits since 1992. Veterans were included if they were 65 years or older as of January 1, 2004; alive through December 2009; and enrolled in Medicare. All women veterans were included because they represent a smaller portion of the overall veteran population. Veterans who were enrolled in Part D during some but not all of 2009 were excluded. Participants were also excluded if they had missing or discrepant demographic, geographic, or medication use data.

Data Sources and Measures

Data for this study were derived from the VA and Medicare administrative databases for years 2008 and 2009. Demographic, geographic, and RxRisk-V risk classes were ascertained in 2008. Medicare Part D enrollment and medication acquisition was examined in 2009. Veterans’ Part D enrollment status was obtained from Medicare enrollment files. Consistent with previous research, a veteran was classified as an MA enrollee if the veteran was enrolled in an MA plan for at least 1 month from January 1, 2008, through December 31, 2009.6 Patient demographic characteristics, including age, race, gender, ethnicity, zip code of residence, and socioeconomic status of the veteran’s zip code of residence (eg, median household income in the zip code), were obtained from the VA Enrollment file22 and US Census Bureau data. Veterans’ priority categories, indicating which veterans are required to make co-payments for no, some, or all medications from VA pharmacies,23 were obtained from the VA Enrollment file. The differential distance between the nearest VA and Medicare-reimbursed facility was calculated using zip code information.12 Rural/urban status was based on Rural Urban Commuting Area Codes derived from zip codes.24

We obtained pharmacy use data from the VA Managerial Cost Accounting National Data Extract Pharmacy data sets25 and the Medicare Part D “Slim” file that contains all prescriptions that have been dispensed and paid through the Part D program. Based on pharmacy use, veterans were classified as 1 of 3 types of pharmacy users: VA only, Part D–reimbursed only, or dual (ie, both VA and Part D–reimbursed). Pharmacy use was measured as the number of 30-day medication supplies (eg, one 90-day supply was equivalent to three 30-day supplies) and the number of drug classes that veterans received from VA and Part D–reimbursed pharmacies.20 A medication with less than a 30-day supply was coded as one 30-day supply. The drug classes were based on the VA drug classification system that provides general categories of drugs and mostly follows the American Hospital Formulary Service Drug Information drug classification.26 For dual pharmacy users, overlapping days’ supply was defined as drug classes that veterans received from both VA and Part D–reimbursed pharmacies with at least 7 overlapping days.

The RxRisk-V is a pharmacy-based case-mix instrument that has been validated in the veteran population14 and can address the issue of missing claims data for veterans enrolled in MA plans. The RxRisk-V contains 45 disease categories based on medication classes (listed in eAppendix Table 1 [eAppendix available at]).27 To construct RxRisk-V scores for a patient population, patient-level pharmacy data are mapped into the RxRisk-V categories. We solicited pharmacist input from our team to review unclassified and new drug classes to identify whether their primary indication is associated with a specific disease state.

The Healthcare Effectiveness Data and Information Set’s list of HRMs28 was used to identify veterans who received HRMs from VA and Part D–reimbursed pharmacies in 2009. HRMs, originally codified by the Beers29 and Zhan30 criteria, are medications that should be avoided in patients 65 years or older because either the associated adverse effects outweigh the potential benefits or there are safer alternatives.

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