Older Americans' Preferences Between Lower Drug Prices and Prescription Drug Plan Choice, 2019.

Objectives. To assess older Americans' willingness to trade off the possibility of choosing or changing their prescription drug plan for lower drug spending.Methods. We used data from the Kaiser Family Foundation Health Tracking Poll on prescription drugs carried out in February 2019. This nationwide telephone survey oversampled participants aged 65 years and older who, when weighted, were representative of the US older adult population.Results. Older adults were strongly in favor of the government negotiating drug prices in Medicare Part D (82% support); 60% of older adults would trade off the possibility of choosing or switching their drug plan in favor of lower drug prices. All groups preferred lower spending over plan choice, but this preference was stronger among individuals who were in poorer health, had lower education and income, and found it very difficult to afford the drugs they needed.Conclusions. The results suggest that Medicare beneficiaries could support policies that limit plan choice, as long as drug prices actually decrease.

Long-acting opioid initiation in US nursing homes.

PURPOSE: To estimate the proportion of residents newly initiating long-acting opioids in comparison to residents initiating short-acting opioids and examine variation in long-acting opioid initiation by region and resident characteristics. METHODS: This cross-sectional study included 182 735 long-stay nursing home residents in 13 881 US nursing homes who were Medicare beneficiaries during 2011 to 2013 and initiated a short-acting or long-acting opioid (excluding residents <50 years old, those with cancer, or receiving hospice care). Medicare Part D prescription claims were used to identify residents as newly initiating short-acting or long-acting opioids, defined as having a prescription claim for an opioid with no prior opioid prescriptions in the preceding 60 days. We estimated the overall proportion of initiators prescribed long-acting opioids. Regional variation was examined by mapping results by state and hospital referral regions. Logistic models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Two percent of opioid initiators were prescribed long-acting opioids. State variation in long-acting opioid initiation ranged from 0.6% to 7.5% (5th-95th percentiles: 0.6-6.4%). Resident characteristics associated with increased long-acting opioid initiation included severe physical limitations (vs none/mild limitations; aOR: 2.13, 95% CI: 1.92-2.37) and pain (staff-assessed vs no pain; aOR: 1.59 95% CI: 1.40-1.80), whereas being non-White was inversely associated (non-Hispanic black vs non-Hispanic white; aOR: 0.70, 95% CI: 0.62-0.79). CONCLUSION: United States nursing home residents predominantly initiate short-acting opioids in accordance with Center for Disease Control and Prevention guidelines. Documented variation by geographic and resident characteristics suggests that improvements are possible.

Comprehensive medication reviews: Optimal delivery setting and recommendations for quality assessment.

OBJECTIVES: To propose a metric evaluating the quality of comprehensive medication reviews (CMRs), and to discuss the optimal setting for CMR delivery. SUMMARY: First, we provide a current assessment of the quality of CMRs performed in community, payer, and health system/clinic settings, with recommended opportunities for improvement. Thereafter, a companion metric for CMR quality is discussed, because this is critical to ensuring that patients are not just receiving CMR services, but that CMRs reflect evidence-based recommendations supporting optimal patient outcomes. CONCLUSION: Based on the data currently available, accessibility to electronic medical records would enhance patient-specific recommendations to optimize CMR delivery and patient outcomes. Future studies may help to identify additional factors, such as pharmacist-physician collaboration in clinic and use of evidence-based recommendations, that can further enhance CMR quality.

Beneficiary, Caregiver, and Case Manager Perspectives on the Medication Therapy Management Program Standardized Format.

Plan sponsors of Medicare Part D must provide beneficiaries who receive a comprehensive medication review (CMR) with a written summary using the Medicare Part D Medication Therapy Management Standardized Format (SF). The SF is a means to advance consistency in the CMR program by providing a template of expected content. However, barriers remain with beneficiary use and integration into existing electronic health records. The current study assessed Medicare beneficiary, caregiver, and case manager perceptions of the SF through five focus group interviews with a total of 23 participants. Qualitative analysis found that beneficiaries and case managers preferred a consolidated SF document to share and update their entire health care team. Beneficiaries suggested adding information to the SF on dosage, timing, drug interactions, cost, and less expensive alternatives. Identifying elements of the SF that are perceived as useful to beneficiaries will allow for a more streamlined SF that may enhance interoperability among the health care team. [Journal of Gerontological Nursing, 45(4), 7-13.].

County and Physician Variation in Benzodiazepine Prescribing to Medicare Beneficiaries by Primary Care Physicians in the USA.

BACKGROUND: Physicians widely prescribe benzodiazepines (BZD) despite well-recognized harms. OBJECTIVE: To determine county and provider characteristics that predict high-intensity BZD prescribing by primary care physicians (PCPs) to Medicare beneficiaries. DESIGN: Cross-sectional analysis of the 2015 Medicare Part D Public Use Files (PUF). SUBJECTS: n = 122,054 PCPs who prescribed 37.3 billion medication days. MAIN MEASURES: Primary outcome was intensity of BZD prescribing (days prescribed/total medication days) at the county- and physician levels. PCP and county characteristics were derived from the Part D PUF, Area Health Resources Files, and County Health Rankings. Logistic regression determined the characteristics associated with high-intensity (top quartile) BZD prescribing. KEY RESULTS: Beneficiaries were prescribed over 1.2 billion days of BZD in 2015, accounting for 2.3% of all medication days prescribed in Part D. Top quartile counties had 3.1 times higher BZD prescribing than the lowest (3.4% vs. 1.1%; F = 3293.8, df = 3, p < 0.001). Adjusting for county-level demographics and health care system characteristics (including supply of mental health providers), counties with more adults with at least some college had lower odds of high-intensity prescribing (per 5% increase, adjusted odds ratio [AOR] 0.80, 99% confidence interval (CI) 0.73-0.87, p < 0.001), as did higher income counties (per US$1000 increase, AOR 0.93, CI 0.91-0.95, p < 0.001). Top quartile PCPs prescribed at 6.5 times the rate of the bottom (3.9% vs. 0.6%; F = 63,910.2, df = 3, p < 0.001). High-intensity opioid prescribing (AOR 4.18, CI 3.90-4.48, p < 0.001) was the characteristic most strongly associated with BZD prescribing. CONCLUSIONS: BZD prescribing appears to vary across counties and providers and is related to non-patient characteristics. Further work is needed to understand how such non-clinical factors drive variation.

An Assessment of Performance Between Medicare Advantage and Stand-Alone Prescription Drug Plans on Two Quality Assurance Measures.

The purpose of our study was to compare performance between Medicare Advantage and stand-alone prescription drug plans on the two quality assurance measures of drug-disease interaction and drug-drug interaction for elderly heart failure beneficiaries. Performance on the drug-disease interaction measure appeared more problematic for stand-alone plan enrollees compared with Medicare Advantage plan enrollees. No statistical difference existed between the plans regarding drug-drug interactions. It appears there may be considerable room for more sophisticated use of disease profiling in the processing of drug claims. The provision of richer clinical data is an essential step to improving performance on the drug-disease interaction measure.

An Assessment of Three Post-Discharge Drug-Based Quality Assurance Events for Elderly Medicare Beneficiaries Enrolled in a Stand-Alone Part D Plan.

This article examines the distribution of drug-based quality assurance events (QAEs) post-discharge across five-day increments and identifies characteristics associated with post-discharge QAEs. Data were obtained through a cross-sectional study of Medicare beneficiaries age 65 and over enrolled in stand-alone Part D plans during calendar year 2010. Our findings suggest an even more compressed timeframe than previously identified in the literature for addressing medication issues among elderly beneficiaries. Specifically, medication reconciliation is needed within two to three days of discharge instead of within 14 days as the literature suggests. To decrease inadvertent readmissions, an immediate in-community medication reconciliation following hospital discharge is needed.

Racial/ethnic disparities in Medicare Part D experiences.

OBJECTIVE: To examine racial/ethnic differences in Medicare beneficiary experiences with Medicare Part D prescription drug (PD) coverage. DATA SOURCES/STUDY SETTING: 2008 Consumer Assessment of Health Care Providers and Systems survey of U.S. Medicare beneficiaries. STUDY DESIGN: Surveys were administered by mail with phone follow-up to a nationally representative sample (61% response rate). This study examines 201,496 beneficiaries of age 65 and older with PD coverage [6% Hispanic, 7% non-Hispanic Black, 3% non-Hispanic Asian or Pacific Islander (API)]. Key variables are self-reported race/ethnicity and Consumer Assessment of Health Care Providers and Systems getting information and needed PDs measures. DATA COLLECTION/EXTRACTION METHODS: We generated weighted case-mix adjusted means for 4 racial/ethnic groups and for Hispanics separately by English-language or Spanish-language preference status. We calculated within-plan disparities using a linear mixed-effect model, with fixed effects for race/ethnicity, coverage type and case-mix variables, and random effects for contract and contract by race/ethnicity interactions. PRINCIPAL FINDINGS: Disparities for Hispanic, Black, and API beneficiaries on obtaining needed PDs and information regarding coverage range from -2 to -11 points (0-100 scale) relative to non-Hispanic Whites, with the greatest disparities observed for Spanish-preferring Hispanics and API beneficiaries, especially those with low income. There is wide variation in disparities across contracts, and contracts with the largest disparities for Hispanics have higher proportions of beneficiaries with lower education and income. CONCLUSIONS: Quality improvement efforts may be needed to reduce racial/ethnic disparities in beneficiary experience with PD coverage. Cultural, language, and health literacy barriers in navigating Medicare's Part D program may partially explain the observed disparities.

Evaluating Success Factors of a Medication Adherence Tracker Pilot Program in Improving Part D Medication Adherence Metrics in a Medicare Advantage Plan: Importance of Provider Engagement.

BACKGROUND: Health plans and providers can increase quality by improving adherence to chronic disease medications included in star ratings among Medicare Advantage Part D (MAPD) plan enrollees. Research is needed to evaluate effective means of collaboration between health plans and providers. The Medication Adherence Tracker (MAT) is a health plan initiative to help primary care providers use outreach to improve their patients' adherence. OBJECTIVE: To quantify the contribution of structural and process factors on the success of a health plan-initiated tracking system in improving chronic disease medication adherence over 6 months. METHODS: The MAT quality improvement initiative was carried out in South Texas from June to December 2016. Health plan pharmacists used claims data to identify MAPD enrollees at risk of nonadherence to triple-weighted star medications: renin-angiotensin system antagonists, oral diabetes medications, and statins. Actionable reports were delivered biweekly to each provider, either by fax or in person, by embedded health plan nurses. Multivariable regression was used to evaluate sociodemographic and clinical factors as well as the role of provider outreach in increasing paid pharmacy claims and medication adherence as measured by proportion of days covered (PDC) > 0.8. RESULTS: Of 3,542 patients in 5 Texas physician-organized delivery system groups whose 67 providers received tracking reports from June through December 2016, 1,901 (54%) patients had more than 1 related prescription, and 3,064 (87%) received provider outreach on at least 1 prescription. 2,493 (70%) had at least 1 paid pharmacy claim. Provider outreach was associated with greater likelihood of paid prescription claims (relative risk [RR] = 4.59, 95% CI = 3.74-5.62) and greater year-end adherence (PDC > 0.8, RR = 1.86, 95% CI = 1.63-2.12) in multivariable predictive models. 95% CIs for age, gender, low-income subsidy eligibility, and number of prescriptions did not exclude the null value. CONCLUSIONS: Provider engagement is critical to effective health plan-provider partnerships to overcome barriers, change behavior, and improve chronic disease care quality and population outcomes. DISCLOSURES: This study was funded by Cigna. The manuscript was prepared as a work for hire. Hong, Esse, Gallardo, Serna, Fosshat, and Mamvou are employees of CareAllies, a Cigna company. Bruce was employed by Cigna at the time of the study. Vadhariya reports a past internship at Regeneron Pharmaceuticals, unrelated to this work. Abughosh reports grants from Regeneron Pharmaceuticals, Valeant Pharmaceuticals, Sanofi, and BMS/Pfizer, unrelated to this work.

Medicare program; standards for e-prescribing under Medicare Part D and identification of backward compatible version of adopted standard for e-prescribing and the Medicare prescription drug program (version 8.1). Final rule.

This final rule adopts uniform standards for medication history, formulary and benefits, and fill status notification (RxFill) for the Medicare Part D electronic prescribing (e-prescribing) drug program as required by section 1860D-4(e)(4)(D) of the Social Security Act (the Act). In addition, we are adopting the National Provider Identifier (NPI) as a standard for identifying health care providers in e-prescribing transactions. It also finalizes the June 23, 2006 interim final rule with comment period that identified the National Council for Prescription Drug Programs (NCPDP) Prescriber/Pharmacist Interface SCRIPT standard, Implementation Guide, Version 8.1 ("NCPDP SCRIPT 8.1") as a backward compatible update of the NCPDP SCRIPT 5.0 ("NCPDP SCRIPT 5.0"), until April 1, 2009. This final rule also retires NCPDP SCRIPT 5.0 and adopts the newer version, NCPDP SCRIPT 8.1, as the adopted standard. Finally, except as otherwise set forth herein, we are implementing our compliance date of 1 year after the publication of these final uniform standards. This is the second set in a continuing process of issuing e-prescribing final standards for the Medicare Part D program,

Medicare Advantage: options for standardizing benefits and information to improve consumer choice.

The Medicare Advantage (MA) program offers beneficiaries a choice of private health plans as alternatives to the traditional fee-for-service Medicare program. MA plans potentially provide additional value, but as plan choices have proliferated, consumers contemplating their options have had difficulty understanding how they differ. Through "standardization" more consistent types of information and a limited number of dimensions along which plans vary--MA plans could reduce complexity and improve beneficiaries' ability to make informed choices. Such standardization steps would offer more meaningful variation in the health coverage options available to beneficiaries, Medicare officials and their community partners would find it far easier to educate beneficiaries about their health plan choices, and beneficiaries would better understand what they were buying. Standardization might also strengthen the ability of the market-based Medicare Advantage program to incorporate beneficiary preferences.

Adjusting Medicare Advantage star ratings for socioeconomic status and disability.

OBJECTIVES: Studies have identified potential unintended effects of not adjusting clinical performance measures in value-based purchasing programs for socioeconomic status (SES) factors. We examine the impact of SES and disability adjustments on Medicare Advantage (MA) plans' and prescription drug plans' (PDPs') contract star ratings. These analyses informed the development of the Categorical Adjustment Index (CAI), which CMS implemented with the 2017 star ratings. STUDY DESIGN: Retrospective analyses of MA and PDP performance using 2012 Medicare beneficiary-level characteristics and performance data from the Star Rating Program. METHODS: We modeled within-contract associations of beneficiary SES (Medicaid and Medicare dual eligibility [DE] or receipt of a low-income subsidy [LIS]) and disability with performance on 16 clinical measures. We estimated variability in contract-level DE/LIS and disability disparities using mixed-effects regression models. We simulated the impact of applying the CAI to adjust star ratings for DE/LIS and disability to construct the 2017 star ratings. RESULTS: DE/LIS was negatively associated with performance for 12 of 16 measures and positively associated for 2 of 16 measures. Disability was negatively associated with performance for 11 of 15 measures and positively associated for 3 of 15 measures. Adjusting star ratings using the CAI resulted in half-star rating increases for 8.5% of MA and 33.3% of PDP contracts that exceeded 50% DE/LIS beneficiaries. CONCLUSIONS: Increases in star ratings following adjustment of clinical performance for SES and disability using the CAI focused on contracts with higher percentages of DE/LIS beneficiaries. Adjustment for enrollee characteristics may improve the accuracy of quality measurement and remove incentives for providers to avoid caring for more challenging patient populations.

Variation in Medication Therapy Management Delivery: Implications for Health Care Policy.

BACKGROUND: Medication therapy management (MTM) program evaluations have revealed mixed outcomes, with some studies finding favorable outcomes and others finding no differences between patients who received MTM versus those who did not. One possible reason for outcomes variability is differences in delivery of MTM programs. The Chronic Care Model (CCM) provides a framework for how health care organizations can improve care for the chronically ill through 6 elements: organization of health care, delivery system design, clinical information systems, decision support, self-management, and linkages to community resources. OBJECTIVE: To apply the CCM to understand variation in MTM delivery and formulate policy recommendations. METHODS: This study used a mixed-methods descriptive analysis of MTM delivery. Investigators conducted visits to a purposeful sample of MTM practices to observe MTM and interview participants. The pharmacists and staff of these practices completed a modified Assessment of Chronic Illness Care (ACIC). Pairs of investigators analyzed interview transcripts to identify themes. Demographics and ACIC scores were summarized using descriptive statistics. After analysis, investigators discussed overarching themes and policy implications organized by CCM elements. RESULTS: Seven practices participated, and 87 participants were interviewed. Based on ACIC scores, MTM patient volume, and payer mix, practices were categorized as Early Maturity Level or Later Maturity Level. From the model, organization of health care themes included whether MTM was the practice's core competence, belief/confidence in the MTM process, lack of formal rewards, and the influence of organizational goals and external environment. Delivery system design themes pertained to the extent that MTM processes were formalized. Clinical information systems themes were the extent to which systems were influenced by payers, efficiency strategies, and the accuracy and availability of information. In considering clinical decision support themes, alert design limitations and variation in user approaches to alerts based on experience were noted. We observed strong support for patient self-management; when present, barriers were attributed to the patient, MTM provider, or payer. Referral to community resources was minimal. Numerous policy implications were identified. CONCLUSIONS: Our research identified numerous ways by which MTM delivery varies, particularly by MTM practice maturity level. These findings provide evidence for several policy changes that could be considered to optimize MTM delivery, encourage alignment with the CCM, and promote practice maturation. DISCLOSURES: This research and a portion of Snyder's salary were supported by grant number K08HS022119 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Snyder reports consulting fees from Westat for an evaluation of the CMS Enhanced MTM program. The other authors have nothing to disclose. Portions of this research have been presented as abstracts at the following conferences: (a) 2017 Academy Health Annual Research Meeting; June 25-27, 2017; New Orleans, LA; (b) 2015 American Society of Health-System Pharmacists Clinical Midyear Meeting; December 4-8, 2015; New Orleans, LA; and

What Patients Know About Services to Help Manage Chronic Diseases and Medications: Findings from Focus Groups on Medication Therapy Management.

BACKGROUND: Managing and treating patients with multiple chronic conditions presents challenges on many levels. Pharmacist-delivered medication therapy management (MTM) services, mandated as part of the Medicare Part D drug benefit, are designed to help patients manage their chronic conditions and medications. OBJECTIVE: To identify factors that influence patient understanding and use of MTM services and potential strategies to educate individuals about MTM. METHODS: Participants who had at least 2 chronic conditions, were taking 2 or more prescription medications, and were aged 18 years or older were recruited from community-based settings to participate in focus groups. The focus groups aimed to identify participants' perceptions and use of MTM services, barriers and facilitators to utilization, and medication problems. Participants were asked to complete a 14-item health care questionnaire and view a brief, 3-minute video introducing the topic of MTM before the group discussion. The health care questionnaire data were analyzed in Microsoft Excel. The focus group responses were transcribed and entered into the computer program ATLAS.ti for thematic analysis. Two independent reviewers qualitatively coded the discussion question responses; a third reviewer investigated discrepancies and facilitated consensus among the reviewers. RESULTS: Participants (N = 27) were mostly female (70.4%), college educated (62.9%), and had Medicare insurance (81.5%). Seven themes were identified: (1) new proposed names for MTM, (2) mechanisms to gain interest in and to promote the value of MTM, (3) familiarity with MTM, (4) pharmacists' training and expertise in MTM, (5) experience with MTM, (6) reasons for nonparticipation in MTM, and (7) preferred method to learn about MTM. Participants did not understand the term "medication therapy management" and felt the interpretation of "therapy"' differed between health care professionals and the public. Some participants used MTM services to learn about appropriate use of their medications, while others were unsure about their eligibility, associated costs, and how to access the services. Participants had limited pharmaceutical knowledge but felt pharmacist-provided MTM services were helpful. Participants were unfamiliar with pharmacists' skills and training. Participants' experiences with MTM services ranged from disregarding the invitation to participate to having pharmacists identify drug-drug interactions. Reasons for nonparticipation in MTM services included being unaware of their eligibility, failing to read excessive information from insurance companies, and being uncertain of the identity of the telephone caller. Preferred methods for learning more about MTM services included the Internet, e-mail, information availability at physician's office, and television advertisements. CONCLUSIONS: These results suggest that the lay public remains largely unaware of MTM services and that the term "MTM" is not well understood. Clearly, tailored public health campaigns and patient engagement strategies are needed to promote MTM in chronic disease management, pharmacists as respected providers, and the importance of the prescriber-MTM pharmacist collaborative relationship in managing medications for patients with multiple chronic conditions. DISCLOSURES: Grant funding from SinfoniaRx to Taylor, Axon, Campbell, Fair, and Warholak was used to help conduct this project. Boesen is employed by SinfoniaRx. The other authors have nothing to disclose. This original research was presented as a poster at the Academy of Managed Care Pharmacy 27th Annual Meeting and Expo; April 7-10, 2015; San Diego, CA.