Currently Viewing:
The American Journal of Managed Care May 2018
Impact of Emergency Physician–Provided Patient Education About Alternative Care Venues
Pankaj B. Patel, MD; David R. Vinson, MD; Marla N. Gardner, BA; David A. Wulf, BS; Patricia Kipnis, PhD; Vincent Liu, MD, MS; and Gabriel J. Escobar, MD
Monitoring the Hepatitis C Care Cascade Using Administrative Claims Data
Cheryl Isenhour, DVM, MPH; Susan Hariri, PhD; and Claudia Vellozzi, MD, MPH
Delivery of Acute Unscheduled Healthcare: Who Should Judge Whether a Visit Is Appropriate (or Not)?
Adam Sharp, MD, MSc, and A. Mark Fendrick, MD
Impact of Formulary Restrictions on Medication Intensification in Diabetes Treatment
Bruce C. Stuart, PhD; Julia F. Slejko, PhD; Juan-David Rueda, MD; Catherine E. Cooke, PharmD; Xian Shen, PhD; Pamela Roberto, PhD; Michael Ciarametaro, MBA; and Robert Dubois, MD
Currently Reading
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
Understanding Factors Associated With Readmission Disparities Among Delta Region, Delta State, and Other Hospitals
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
Increasing Hepatitis C Screening in a Large Integrated Health System: Science and Policy in Concert
Carla V. Rodriguez, PhD; Kevin B. Rubenstein, MS; Benjamin Linas, MD; Haihong Hu, MS; and Michael Horberg, MD
Nevada's Medicaid Expansion and Admissions for Ambulatory Care–Sensitive Conditions
Olena Mazurenko, MD, PhD; Jay Shen, PhD; Guogen Shan, PhD; and Joseph Greenway, MPH
Introduction of Cost Display Reduces Laboratory Test Utilization
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.
DISCUSSION

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.

Limitations

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.

CONCLUSIONS

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. 

Acknowledgments

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: tmarkossian@luc.edu.
REFERENCES

1. Feldman R, Dowd B, Wrobel M. Risk selection and benefits in the Medicare+Choice program. Health Care Financ Rev. 2003;25(1):23-36.

2. Maciejewski ML, Dowd B, O’Connor H. Multiple prior years of health expenditures and Medicare health plan choice. Int J Health Care Finance Econ. 2004;4(3):247-261. doi: 10.1023/B:IHFE.0000036049.40865.72.

3. Ng JH, Kasper JD, Forrest CB, Bierman AS. Predictors of voluntary disenrollment from Medicare managed care. Med Care. 2007;45(6):513-520. doi: 10.1097/MLR.0b013e31802f91a5.

4. Langwell KM, Hadley JP. Evaluation of the Medicare competition demonstrations. Health Care Financ Rev. 1989;11(2):65-80.

5. Rossiter LF, Langwell KM, Brown R, Adamache KW, Nelson L. Medicare’s expanded choices program: issues and evidence from the HMO experience. Adv Health Econ Health Serv Res. 1989;10:3-40.

6. Maciejewski ML, Birken S, Perkins M, Burgess JF Jr, Sharp N, Liu CF. Medicare managed care enrollment by disability-eligible and age-eligible veterans. Med Care. 2009;47(11):1180-1185. doi: 10.1097/MLR.0b013e3181b58e17.

7. Shimada SL, Zaslavsky AM, Zaborski LB, O’Malley AJ, Heller A, Cleary PD. Market and beneficiary characteristics associated with enrollment in Medicare managed care plans and fee-for-service. Med Care. 2009;47(5):517-523. doi: 10.1097/MLR.0b013e318195f86e.

8. Potosky AL, Merrill RM, Riley GF, et al. Breast cancer survival and treatment in health maintenance organization and fee-for-service settings. J Natl Cancer Inst. 1997;89(22):1683-1691.

9. Riley GF, Potosky AL, Klabunde CN, Warren JL, Ballard-Barbash R. Stage at diagnosis and treatment patterns among older women with breast cancer: an HMO and fee-for-service comparison. JAMA. 1999;281(8):720-726. doi: 10.1001/jama.281.8.720.

10. Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med. 2005;353(7):692-700. doi: 10.1056/NEJMsa051207.

11. Shen Y, Hendricks A, Li D, Gardner J, Kazis L. VA–Medicare dual beneficiaries’ enrollment in Medicare HMOs: access to VA, availability of HMOs, and favorable selection. Med Care Res Rev. 2005;62(4):479-495. doi: 10.1177/1077558705277396.

12. Petersen LA, Byrne MM, Daw CN, Hasche J, Reis B, Pietz K. Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans. Health Serv Res. 2010;45(3):762-791. doi: 10.1111/j.1475-6773.2010.01107.x.

13. Fetter R. DRG Refinement With Diagnosis Specific Comorbidities and Complications: A Synthesis of Current Approaches to Patient Classification: Final Report. New Haven, CT: Yale University Press; 1989.

14. Ash A, Porell F, Gruenberg L, Sawitz E, Beiser A. Adjusting Medicare capitation payments using prior hospitalization data. Health Care Financ Rev. 1989;10(4):17-29.

15. Weiner JP, Starfield BH, Steinwachs DM, Mumford LM. Development and application of a population-oriented measure of ambulatory care case-mix. Med Care. 1991;29(5):452-472.

16. Fischer MJ, Stroupe KT, Kaufman JS, et al. Predialysis nephrology care among older veterans using Department of Veterans Affairs or Medicare-covered services. Am J Manag Care. 2010;16(2):e57-e66.

17. Keating NL, Landrum MB, Lamont EB, Earle CC, Bozeman SR, McNeil BJ. End-of-life care for older cancer patients in the Veterans Health Administration versus the private sector. Cancer. 2010;116(15):3732-3739. doi: 10.1002/cncr.25077.

18. Liu CF, Bryson CL, Burgess JF Jr, Sharp N, Perkins M, Maciejewski ML. Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients. BMC Health Serv Res. 2012;12:51. doi: 10.1186/1472-6963-12-51.

19. Petersen LA, Normand SL, Daley J, McNeil BJ. Outcome of myocardial infarction in Veterans Health Administration patients as compared with Medicare patients. N Engl J Med. 2000;343(26):1934-1941. doi: 10.1056/NEJM200012283432606.

20. Stroupe KT, Smith BM, Bailey L, et al. Medication acquisition by veterans dually eligible for Veterans Affairs and Medicare Part D pharmacy benefits. Am J Health Syst Pharm. 2017;74(3):140-150. doi: 10.2146/ajhp150800.

21. Veterans Health Administration. 2011 Survey of Veteran Enrollees’ Health and Reliance Upon VA. Washington, DC: Department of Veterans Affairs; 2012. va.gov/healthpolicyplanning/soe2011/soe2011_report.pdf. Accessed January 19, 2017.

22. US Department of Veterans Affairs Information Resource Center. VIReC Research User Guide: VHA Assistant Deputy Under Secretary of Health (ADUSH) Enrollment Files. 2nd ed. Hines, IL: US Department of Veterans Affairs, Health Services Research & Development Service, Information Resource Center; 2013.

23. Morgan RO, Petersen LA, Hasche JC, et al. VHA pharmacy use in veterans with Medicare drug coverage. Am J Manag Care. 2009;15(3):e1-e8.

24. Abrams TE, Vaughan-Sarrazin M, Kaboli PJ. Mortality and revascularization following admission for acute myocardial infarction: implication for rural veterans. J Rural Health. 2010;26(4):310-317. doi: 10.1111/j.1748-0361.2010.00318.x.

25. US Department of Veterans Affairs Information Resource Center. VIReC Research User Guide: VHA Pharmacy Prescription Data. 2nd ed. Hines, IL: US Department of Veterans Affairs, Health Services Research & Development Service, Information Resource Center; 2008.

26. AHFS pharmacologic-therapeutic classification. American Society of Health-System Pharmacists website. ahfsdruginformation.com/ahfs-pharmacologic-therapeutic-classification. Accessed January 19, 2017.

27. Sloan KL, Sales AE, Liu CF, et al. Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument. Med Care. 2003;41(6):761-774. doi: 10.1097/01.MLR.0000064641.84967.B7.

28. HEDIS 2009 NDC lists, Use of high-risk medications in the elderly, table DAE-A: high-risk medications 2009. ncqa.org/hedis-quality-measurement/hedis-measures. Accessed January 19, 2017.

29. Fick DM, Semla TP. 2012 American Geriatrics Society Beers Criteria: new year, new criteria, new perspective. J Am Geriatr Soc. 2012;60(4):614-615. doi: 10.1111/j.1532-5415.2012.03922.x.

30. Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA. 2001;286(22):2823-2829. doi: 10.1001/jama.286.22.2823.

31. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011.

32. Chen JH, Humphreys K, Shah NH, Lembke A. Distribution of opioids by different types of Medicare prescribers. JAMA Intern Med. 2016;176(2):259-261. doi: 10.1001/jamainternmed.2015.6662.

33. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-1382. doi: 10.15585/mmwr.mm6450a3.

34. Yarbrough CR. Prescription drug monitoring programs produce a limited impact on painkiller prescribing in Medicare Part D [published online January 18, 2017]. Health Serv Res. doi: 10.1111/1475-6773.12652.

35. Stroupe KT, Smith BM, Bailey L, et al. Medication utilization of veterans dually eligible for VA and Medicare Part D pharmacy benefits. Am J Health Syst Pharm. 2017;74(3):140-150. doi: 10.2146/ajhp150800.

36. Qato DM, Trivedi AN. Receipt of high risk medications among elderly enrollees in Medicare Advantage plans. J Gen Intern Med. 2013;28(4):546-553. doi: 10.1007/s11606-012-2244-9.

37. Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169(3):305-311. doi: 10.1001/archinternmed.2008.551.

38. Lehnbom EC, Stewart MJ, Manias E, Westbrook JI. Impact of medication reconciliation and review on clinical outcomes. Ann Pharmacother. 2014;48(10):1298-1312. doi: 10.1177/1060028014543485.

39. Stroupe KT, Smith BM, Hogan TP, et al. Medication acquisition across systems of care and patient-provider communication among older veterans. Am J Health Syst Pharm. 2013;70(9):804-813. doi: 10.2146/ajhp120222.

40. Stevenson FA, Barry CA, Britten N, Barber N, Bradley CP. Doctor-patient communication about drugs: the evidence for shared decision making. Soc Sci Med. 2000;50(6):829-840.
PDF
 
Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
x
Welcome the the new and improved AJMC.com, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up