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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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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.

Almost one-fourth of Medicare-eligible veterans were enrolled in an MA plan for at least 1 month in 2008-2009, representing more than 1 million veterans enrolled in the VA and Medicare. A higher proportion of MA patients (73.7%) enrolled in Medicare Part D compared with FFS patients (24.3%). Moreover, a significantly higher portion of MA enrollees (17.0%) compared with the FFS enrollees (14.3%) were receiving HRMs. MA plan enrollees also differed from FFS sector enrollees in several of the demographic, geographic, and clinical characteristics that we examined.

The percentage of patients with common clinical conditions differed significantly between MA and FFS enrollees, with the largest percentage difference between the 2 groups being for pain. Veterans with pain had higher odds of enrollment in MA plans versus FFS plans. One possible explanation could be access to pain medications through the Medicare Part D program, with 73.7% of MA enrollees being enrolled in Part D versus just 24.3% of the FFS enrollees. Chronic pain is frequently encountered in the United States; it affects an estimated 20% of the population.31 Opiates are used routinely for the treatment of pain and frequently overprescribed.32 Prescriptions for opioids have decreased slightly, but opioid-related overdoses continue to increase and have been associated with an epidemic of opioid abuse, dependence, and overdose.33 Opioid analgesics were the third most frequent class of medications acquired from Part D–reimbursed pharmacies for both Medicare FFS and MA enrollees. Notably, opioid analgesics were not on the list of frequent classes of medications acquired from VA pharmacies. Since the recent implementation of state-level prescription drug monitoring programs, providers within the VA can henceforth explore the receipt of these medications by veterans from outside the VA system.34

We found that MA-enrolled veterans used more medications and were more likely dual or Medicare-only pharmacy users compared with the FFS sector enrollees. In a previous study of FFS-enrolled veterans, results showed that a substantial proportion of veterans received their medications from Part D–reimbursed and VA pharmacies.35 According to the authors, this might pose safety risks if providers in one healthcare system did not know about medications prescribed by providers in another system. Our results showed that the potential safety risks associated with dual pharmacy use among MA-enrolled veterans might be much greater because these veterans are more likely to be dual pharmacy users than those in the FFS sector (32.3% vs 7.0%). Similar to the previous study, we also found that some of the medications filled at Part D–reimbursed pharmacies were drugs that carried a significant drug–drug interaction profile (eg, quinolones) or included narcotics that require cross-system monitoring to control potential abuse and diversion. Antidepressants and opioid analgesics were on the list of most frequent drug classes that dual pharmacy users obtained from both Part D–reimbursed and VA pharmacies with overlapping supply days.

In 2009, a previous study found that 21.5% of MA enrollees received at least 1 HRM.36 In our study, 15.1% of the veterans received HRMs. The proportion was significantly higher among dual (24.4%) and Part D–reimbursed (20.7%) pharmacy users compared with VA-only pharmacy users (10.1%) (P <.001). Because MA enrollees were more likely to be dual or Medicare-only pharmacy users, the proportion of HRMs was significantly higher for MA enrollees (17.0%) compared with those in the FFS sector (14.3%) (P <.001). The computerized patient record system at the VA alerts physicians about prescribing HRMs for elderly veterans. Although alert fatigue is a well-documented phenomenon,37 our data demonstrate that a significant proportion of HRMs are received from outside of the VA system. Other possible reasons for lower receipt of HRMs from VA pharmacies include availability of alternative nonpharmacological treatments at the VA, norms and training practices of VA providers, and availability of onsite pharmacists at the VA.


There are limitations to this descriptive study. Due to constraints in VA administrative data, we were not able to assess relevant veteran characteristics, including education level, income, or preference for care, that might impact their choice of Medicare plan. As proxies for these variables, we used the socioeconomic status of the veterans’ zip code of residence, veterans’ priority categories, and the differential distance between the nearest VA and Medicare-reimbursed facility. Veterans who did not use medications in 2008 from VA or Medicare-reimbursed pharmacies were not classified by the RxRisk-V. This may have decreased the prevalence of the chronic conditions in our population if veterans received medications that are not covered by either VA or Medicare benefits. Also, RxRisk-V assigns disease categories based on treatment for conditions, and plan choice may impact treatment for conditions. Because the VA serves a unique population, which is predominately male and older and has low socioeconomic status, our results demonstrating differences in patient sociodemographic, clinical, and medication use by plan enrollment status may not be generalizable to other settings or populations. Although the data are from 2009, the findings inform current policy discussions because they highlight the importance of coordinating multiple system use, which is a major issue in the current US healthcare system. Finally, although our list of HRMs was specific to the elderly, it did not include all medications with safety concerns (eg, QTc interval prolongation with quinolones or bleeding with warfarin). Therefore, our results regarding the prevalence of HRMs should be considered a conservative estimate of the use of medications with safety concerns in an elderly population.


Medication reconciliation within health systems can identify medication discrepancies and reduce potential harm.38 Most electronic health records (EHRs), including VA’s health information system, allow providers to add services or medications received outside their health system. However, this process relies on providers asking patients for this information and documenting it in the EHR as non-VA medication orders. According to findings of a previous study, more than 38% of veterans who obtained non-VA medications did not discuss these medications with VA physicians.39 Studies outside the VA system have also found that doctor–patient communication about drugs was suboptimal.40

Our results highlight that MA enrollees were more likely to be dual or Medicare-only pharmacy users compared with the FFS sector enrollees. These veterans acquired many drug classes, such as opioid analgesics, more frequently from Part D–reimbursed pharmacies than from VA pharmacies. Providers both inside and outside of the VA caring for veterans should consider that substantial information about the medication profiles of their patients might be unavailable in their healthcare systems’ EHRs, and they should ask patients for this information. 


The authors wish to thank Fran Cunningham, PharmD, director, and Muriel Burk, PharmD, clinical pharmacy specialist, at the VA Center for Medication Safety (Hines, IL) for reviewing earlier drafts of the manuscript.

Author Affiliations: Center for Innovation in Complex Chronic Healthcare, Hines VA Hospital (TWM, KJS, ZH, BMS, KTS), Hines, IL; Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago (TWM, KTS), Maywood, IL; Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy (KJS), and Division of Epidemiology and Biostatistics, School of Public Health (LA), University of Illinois at Chicago, Chicago, IL; Department of Pediatrics, Feinberg School of Medicine, Northwestern University (BMS), Chicago, IL.

Source of Funding: This study was supported by the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service, as grant IIR 07-165-2. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (TWM, KJS, BMS, KTS); acquisition of data (TWM, ZH, BMS, KTS); analysis and interpretation of data (TWM, KJS, LA, ZH, BMS, KTS); drafting of the manuscript (TWM, KJS); critical revision of the manuscript for important intellectual content (TWM, KJS, BMS, KTS); statistical analysis (TWM, LA, ZH); obtaining funding (BMS, KTS); administrative, technical, or logistic support (KJS); supervision (KTS); and data definition files (KJS).

Address Correspondence to: Talar W. Markossian, PhD, Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago, 2160 S First Ave, CTRE 554, Maywood, IL 60153. Email:

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