Volume of Cataract Surgery and Surgeon Gender: The Florida Ambulatory Surgery Center Experience 2005 Through 2012.

Cataract is the most common surgically reversible cause of vision loss and the most common major surgical procedure performed in the United States. To understand how gender composition might affect differences in health services, we examined the surgeon gender-specific rates of routine cataract surgery performed in ambulatory surgical centers in Florida. Routine cataract surgeries were identified through the Florida Agency for Health Care Administration (AHCA) ambulatory surgery center dataset. The background of individual surgeons was determined by linking license numbers in the dataset to physician profiles publicly available from AHCA. From 2005 through 2012, women ophthalmologists in Florida performed roughly half the annual rate of cataract surgery as their male counterparts. This difference is not explained by greater time in clinical practice for men. Further investigation into the causes of this gender-volume disparity is warranted to determine what roles choice and barriers may play.

Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study.

BACKGROUND: Low health literacy is associated with higher health care utilization and costs; however, no large-scale studies have demonstrated this in the Veterans Health Administration (VHA). This research evaluated the association between veterans' health literacy and their subsequent VHA health care costs across a three-year period. METHODS: This retrospective study used a Generalized Linear Model to estimate the relative association between a patient's health literacy and VHA medical costs, adjusting for covariates. Secondary data sources included electronic health records and administrative data in the VHA (e.g., Medical and DCG SAS Datasets and DSS-National Data Extracts). Health literacy assessments and identifiers were electronically retrieved from the originating health system. Demographic and cost data were retrieved from the VHA centralized databases for the corresponding patients who had VHA use in all three years. RESULTS: In a study of 92,749 veterans with service utilization from 2007-2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581 [95 % CI: $30,186 - $32,975]; $23,508 [95 % CI: $22,749 - $24,268]) than adequate health literacy ($17,033 [95 % CI: $16,810 - $17,255]). Estimated three-year cost associated with veterans' with marginal and inadequate health literacy was $143 million dollars more than those with adequate health literacy. CONCLUSIONS: Analyses suggest when controlling for other person-level factors within the VHA integrated healthcare system, lower health literacy is a significant independent factor associated with increased health care utilization and costs. This study confirms the association of lower health literacy with higher medical service utilization and pharmacy costs for veterans enrolled in the VHA. Confirmation of higher costs of care associated with lower health literacy suggests that interventions might be designed to remediate health literacy needs and reduce expenditures. These analyses suggest 17.2 % (inadequate & marginal) of the Veterans in this population account for almost one-quarter (24 %) of VA medical and pharmacy cost for this 3-year period. Meeting the needs of those with marginal and inadequate health literacy could produce potential economic savings of approximately 8 % of total costs for this population.

Improving identification of fall-related injuries in ambulatory care using statistical text mining.

OBJECTIVES: We determined whether statistical text mining (STM) can identify fall-related injuries in electronic health record (EHR) documents and the impact on STM models of training on documents from a single or multiple facilities. METHODS: We obtained fiscal year 2007 records for Veterans Health Administration (VHA) ambulatory care clinics in the southeastern United States and Puerto Rico, resulting in a total of 26 010 documents for 1652 veterans treated for fall-related injury and 1341 matched controls. We used the results of an STM model to predict fall-related injuries at the visit and patient levels and compared them with a reference standard based on chart review. RESULTS: STM models based on training data from a single facility resulted in accuracy of 87.5% and 87.1%, F-measure of 87.0% and 90.9%, sensitivity of 92.1% and 94.1%, and specificity of 83.6% and 77.8% at the visit and patient levels, respectively. Results from training data from multiple facilities were almost identical. CONCLUSIONS: STM has the potential to improve identification of fall-related injuries in the VHA, providing a model for wider application in the evolving national EHR system.

Use of outpatient mental health services by homeless veterans after hurricanes.

Little is known about the impact of hurricanes on people who are homeless at the time a disaster occurs. Although researchers have extensively studied the psychosocial consequences of disaster produced homelessness on the general population, efforts focused on understanding how homeless people fare have been limited to a few media reports and the gray literature. In the event of a hurricane, homeless veterans may be at increased risk for negative outcomes because of their cumulative vulnerabilities. Health care statistics consistently document that homeless veterans experience higher rates of medical, emotional, substance abuse, legal, and financial problems compared with the general population. This study used the 2004 to 2006 Veterans Health Administration (VHA) Outpatient Medical Dataset to examine the effects of hurricanes on use of outpatient mental health services by homeless veterans. Homeless veterans residing in hurricane-affected counties were significantly more likely to participate in group psychotherapy (32.4% vs. 13.4%, p < .002), but less likely to participate in individual 30-40-min sessions with medical evaluations (3.5% vs. 17.3%, p < .001). The study findings have implications for homeless programs and the provision of VHA mental health services to homeless veterans postdisaster.

Do ophthalmology training programs affect corrective procedure rates after cataract surgery?

The Veterans Health Administration (VHA) plays a major role in training surgeons in the United States. This study examined the rates of corrective procedures after routine cataract surgery stratified for VHA institutions according to the presence or absence of ophthalmology training programs. There was a wide range of rates of corrective surgeries in the 111 centers that performed cataract surgery. VHA medical centers affiliated with training programs had nearly twice the rates of corrective surgery after cataract extraction than those institutions without such programs. Variation in secondary procedure rates has implications for the development of quality improvement in ophthalmology.

Posttraumatic stress disorder and use of psychiatric and alcohol related services: the effect of the 2004-2005 Florida hurricane seasons on veterans.

The purpose of this study was to document preliminary findings of the association between posttraumatic stress disorder (PTSD), mental health service use, and alcohol related health visits among veterans following 2004-2005 Florida hurricane seasons. A retrospective review of the Veterans Health Administration Medical SAS Outpatient Dataset was conducted to identify veterans residing in Florida during the 2004-2005 hurricane seasons with a history of PTSD and/or PTSD and a substance use disorder. It was found that veterans with PTSD residing in counties affected by hurricanes demonstrated an immediate 28 % increase in use of mental health services following hurricane landfall versus veterans residing in non-hurricane affected counties (+28.0 vs. -6.5 %, p = 0.001). Additionally, veterans residing in affected counties were found to use more group psychotherapy treatment sessions overall (30.3 vs. 27.2 %, p = 0.001). Of note, veterans with PTSD experienced a -0.16 per month (p = 0.114) decrease in alcohol related visits following the 2004 hurricane season. These findings provide insight into the mental health needs of veterans with PTSD following a disaster and can inform delivery of services to veterans with PTSD and alcohol related issues in disaster prone areas.

Comparison of complication rates in veterans receiving cataract surgery through the Veterans Health Administration and Medicare.

BACKGROUND: To compare the 90-day rates of select secondary procedures after cataract extraction in patients having fee-for-service surgery under Medicare to surgeries provided through the Veterans Health Administration (VHA) during the same calendar year. METHODS: Medicare, VHA, and VHA Fee Basis Program data for calendar year 2007 were merged to identify a cohort of veterans that had outpatient cataract surgery. Secondary surgeries were tracked using selected Current Procedural Terminology (CPT) codes as surrogate markers for complications. Primary surgery and corrective surgeries were linked through right and left eye CPT modifier codes. Risks of complications were adjusted for race, age, sex, and ocular and medical comorbidities. RESULTS: A total of 223,873 cataract extractions were performed on veterans during calendar year 2007, 88.4% of which were provided through Medicare. The 90-day overall rate of CPT-coded secondary procedures was greater for patients having cataract surgery through the VHA (37.2 per 1000 surgeries) than Medicare (18.2 per 1000 surgeries). The overall rate was influenced primarily by higher rates of vitrectomy and related procedures, after both routine and complex cataract extractions. The adjusted odds ratio of vitrectomy within 90 days of routine cataract surgery in the VHA with reference to Medicare was 3.77 (95% confidence interval, 3.44-4.14). CONCLUSIONS: In 2007, the pattern and rates of secondary surgeries after cataract extraction varied between the Medicare and the VHA programs. If these results are confirmed, further research to identify the sources of higher secondary procedure rates is warranted to enhance patient safety.

Incidence and cost of serious fall-related injuries in nursing homes.

BACKGROUND: Fall-related injuries (FRIs) result in morbidity and mortality for patients, as well as unnecessary expense to health care institutions. OBJECTIVES: (a) Estimate the incidence of falls and FRIs with a nursing home as the source of admission in Veterans Administration (VA) and non-VA facilities. (b) Estimate the cost of hospitalizations for each level of FRI severity. RESEARCH DESIGN: Retrospective analysis of falls and FRI resulting in a hospitalization whose source of admission was a VA nursing home. DATA: Falls and FRIs were obtained from Minimum Data Set (MDS) reports (January 2007-June 2009). Costs were obtained from the VA Decision Support System reports and Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) reports (2000-2006). MEASURES: Incidence of falls, fracture incidence, number of hospitalizations for FRIs, and costs associated with hospitalization for by level of FRI severity. RESULTS: Fall incidence was 10.6% in VA and 13.1% in CMS facilities. Fracture incidence was 0.9% in VHA and 1.65% in CMS facilities. Over a 3-year period, there were 2,400 admissions to VHA hospitals for FRI, with 55.4% hip fractures and10.1% intracranial injuries, with an average cost of US$23,723 per admission. Over a 9-year period, there were 141,308 admissions from nursing homes to non-VA hospitals for FRIs, with 38.8% hip fractures, 35.7% other fractures, and 11.1% intracranial injuries, with an average cost of US$31,507 per admission. CONCLUSIONS: Prevention program emphasis should shift away from a focus on preventing falls as a measure of quality care to decreasing FRIs. These findings support implementation of injury prevention programs for the elderly that reduces risk for injury as the primary outcome.

Factors associated with program utilization of radiation therapy treatment for VHA and medicare dually enrolled patients.

We examine how distance to a Veterans Health Administration (VHA) facility, patient hometown classification (e.g., small rural town), and service-connected disability are associated with veterans' utilization of radiation therapy services across the VHA and Medicare. In 2008, 45,914 dually-enrolled veteran patients received radiation therapy. Over 3-quarters (35,513) of the patients received radiation therapy from the Medicare program. Younger age, male gender, shorter distance to a VHA facility, and VHA priority or disability status increased the odds of utilizing the VHA. However, veterans residing in urban areas were less likely to utilize the VHA. Urban dwelling patients' utilization of Medicare instead of the VHA suggests a complex decision that incorporates geographic access to VHA services, financial implications of veteran priority status, and the potential availability of multiple sources of radiation therapy in competitive urban markets.

All-cause mortality rates of hip fractures treated in the VHA: do they differ from Medicare facilities?

PURPOSE: To estimate the 1-year all-cause mortality rates for hip fracture (HFx) patients hospitalized at Veterans Health Administration (VHA) facilities and compare with previous published mortality rates for veterans treated in Medicare facilities. METHODS: In total, 7 years of VHA discharge data on HFxs for 12,539 patients age 65 and older were combined with national death registry data. We performed a 1-year survival analysis using the Cox proportional hazard method. RESULTS: The adjusted rates for veterans treated in the VHA (30 days=9.3%, 90 days=17.5%, 180 days=23.3%, 365 days=29.8%) were similar to veterans treated in Medicare facilities (30 days=8.9%, 90 days=15.6%, 180 days=21.8%, 365 days=29.9%). For veterans treated for a HFx in Medicare facilities, the average length of stay was 7 days and 49% were discharged to a nursing home. Veterans treated in the VHA had an average length of stay of 14 days and only 35% were discharged to a nursing home. CONCLUSIONS: Our study suggests no difference in HFx-adjusted mortality rates between the VHA and Medicare facilities. Given the institutional factor differences between Medicare and the VHA, future study and comparison of health outcomes for nursing home HFx patients and related costs between these two health care programs may contribute to the on-going health care reform debate.

Cataract surgery among veterans 65 years of age and older: analysis of national veterans health administration databases.

The authors examine the rates of cataract surgery as a crude measure of appropriateness of care among veterans 65 years of age and older who use Veterans Health Administration (VHA). Data were obtained from the national VHA data sets for fiscal years 2000 through 2007, using International Classification of Diseases codes and the American Medical Association's Current Procedural Terminology codes. Cataract surgery was expressed as procedures per 10 000 veteran beneficiaries per fiscal year. The annual incidence of cataract surgery increased marginally over the study period with an average annual incidence of 105.8 surgeries per 10 000 beneficiaries. Institutional rates of VHA surgery differ substantially from those of Medicare beneficiaries, which are approximately 5.5-fold greater. Although direct comparison must be interpreted cautiously, the difference is too great to be explained by demographic factors or secular trends in surgery. Additional research is required to elucidate factors that influence the rate of cataract surgery in the VHA.

Central nervous system and musculoskeletal medication profile of a veteran cohort with blast-related injuries.

Little is known about the utilization of central nervous system (CNS) and musculoskeletal (MS) medications in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans with blast-related injuries (BRIs). We followed prescription drug use among a cohort of 133 OIF/OEF veterans with BRIs by using the Joint Theatre Trauma Registry, the Tampa Polytrauma Registry, and electronic medical records. We extracted 12 months of national medication records from the Veterans Health Administration Decision Support System and analyzed them with descriptive statistics. Over the 12-month period (fiscal year 2007), CNS medications comprised 27.9% (4,225/15,143) of total prescriptions dispensed to 90.2% (120/133) of our cohort. Approximately one-half (48.9%) of the 133 patients were treated with opioid analgesics. Nearly 60% received antidepressants. More than one-half (51.1%) of patients were treated with anticonvulsants. Benzodiazepines and antipsychotics were dispensed to 17.3% and 15.8%, respectively. For MS medicines, 804 were prescribed for 48.1% (64/133) of veterans. Nearly one-fourth (24.8%) were treated with skeletal muscle relaxants. The CNS and MS medications, in general, were continuously prescribed over the 12-month study period. This study provides insight into the complex medical management involved in the care of veterans with BRIs.

Acquisition costs and use of Medicare Part D-excluded drugs in Veterans Health Administration long-stay nursing home residents: a national, descriptive, secondary data analysis.

BACKGROUND: Nursing home populations may consist of both short- and long-stay residents, who have different resource use profiles. Differentiating between these two populations is important in any analysis of drug costs and use. OBJECTIVE: The aim of this analysis was to provide national annualized estimates of drug acquisition costs and use of drugs excluded under Medicare Part D for dually eligible long-stay nursing home residents in the US. METHODS: This was a national, descriptive, secondary data analysis. The study population consisted of 6554 Veterans Health Administration (VHA) long-stay nursing home residents (n=136 nursing homes), identified from the Minimum Data Set (MDS), who had an annual assessment during fiscal year (FY) 2005 linked with their 8,847,561 inpatient pharmacy claims. The study data generated were descriptive statistics of the annual drug acquisition costs and use of medications excluded under Medicare Part D. VHA therapeutic drug classes were obtained from FY 2005 national pharmacy claims linked at the individual resident level. RESULTS: The excluded drugs accounted for 3 036 306 of the more than 8.8 million inpatient pharmacy claims, totalling $US3,406,756 or $US526 per resident (99% CI 490, 562). Non-opioid analgesics were received by 73.3% of the residents, totalling $US352,608 or $US73 per resident; 25.3% received antitussives, decongestants, or cold and cough medications, totalling $US27,220 or $US16 per resident; 63.8% received vitamins, totalling $US281,909 or $US67 per resident; 17.7% received benzodiazepines or sedative hypnotics, totalling $US76,083 or $US66 per resident; and 64.3% received laxatives or stool softeners, totalling $US298,326 or $US71 per resident. The total acquisition cost of all drugs was $US23,782,717 for 6554 VHA nursing home residents or $US3629 per resident (99% CI 3343, 3915). CONCLUSION: The cost of Medicare Part D-excluded drugs represented a fraction of the total VHA drug costs for long-stay nursing home residents, accounting for only 14.3% of all drug costs and 34.3% of the more than 8.8 million inpatient pharmacy claims. More research is needed to account for the drug dispensing and administration costs associated with these excluded classes of drugs and their efficacy. Studies of VHA drug acquisition costs provide important policy-relevant data for the Medicare Part D national price negotiation debate, particularly in a US presidential election year.

Benchmark data on the utilization and acquisition costs of central nervous system and muscular skeletal drugs among veterans with combat-related injuries.

BACKGROUND: Little is known about the utilization and costs of central nervous system (CNS) and musculoskeletal medications in veterans with blast injuries. METHODS: Two years of national medication records of Operations Enduring Freedom and Iraqi Freedom veterans with blast injuries were extracted from the Veterans Health Administration Decision Support System and analyzed with descriptive statistics. RESULTS: Over the 2-year period, there was a total of 23,795 pharmacy claims (various drug classes) for 60 patients with blast injuries with a 2-year drug acquisition cost of $111,535 (mean per patient = $1,858; median per patient = $960). There were 6,471 CNS pharmacy claims or 4.5 CNS pharmacy claims per patient per month. Over four (81.6%) of five veterans were prescribed opioid analgesics; 75.0% (45 of 60) received antidepressants; 68.3% (41 of 60) received anticonvulsants; 40% (24 of 60) received antipsychotics; and 41.6% (25 of 60) received sedative hypnotics. The drug acquisition cost of all CNS medications was $46,384 ($7.17 per claim) and accounted for over 41% of total medication spending. For musculoskeletal medications, there were 1,253 pharmacy claims for 32 patients or 53% of the cohort costing $5,015 ($4.00 per claim), which accounted for 4.5% ($5,015 of $111,535) of total medication spending. CONCLUSIONS: The analysis suggests that these combat-wounded veterans were discharged on CNS medications with potential side effects, although the magnitude of these side effects, if any, remains unknown.

Long-stay nursing home residents' hospitalizations in the VHA: the potential impact of aligning financial incentives on hospitalizations.

OBJECTIVES: The aim of this study was to provide national annualized descriptive statistics of the hospital admissions for long-stay nursing home residents. DESIGN: National, descriptive, secondary data analysis. SETTING: National, Veterans Health Administration (VHA), 136 VHA nursing homes. PARTICIPANTS: Our study population consisted of 6554 VHA long-stay nursing home residents who had an annual assessment during FY 2005, identified from the Minimum Data Set (MDS). These residents were linked with the national VHA discharge dataset. MEASUREMENT: We provide descriptive statistics of the major diagnostic categories (MDC) and diagnosis related groups (DRG) for long-stay residents admitted to a VHA hospital where the source of admission was from the VHA nursing home. RESULTS: Overall, 28.57% (1873/6554) of VHA long-stay residents were hospitalized. The top 5 MDC accounted for over 70% of the hospitalizations. The frequency of MDC associated with hospital admissions, in descending order, were respiratory system (25.33%), kidney and urinary tract (15.88%), circulatory (14.65%), digestive system (9.39%), and nervous system (5.16%). Nearly 25,000 bed days of care (BDC) were associated with these hospitalizations. The top 3 DRG (DRG 320- Med kidney & urinary tract, 89-Med simple pneumonia & pleurisy, 79-Med respiratory infections & inflammations) accounted for nearly 25% of all the hospitalizations and approximately 23% of the BDC. CONCLUSIONS: VHA nursing homes do not have the financial incentives that impact the decision to hospitalize that exist in the non-VHA sector. This unique feature of the VHA's nursing homes would allow one to study the issue of potentially preventable hospitalizations in long-stay residents without the confounding impact of Medicare and Medicaid payment incentives. Because of the importance of this policy issue in the national long-term care debate, further VHA studies may provide important empirically based policy input.

Rehospitalization after hip fracture: predictors and prognosis from a national veterans study.

OBJECTIVES: To estimate the risk and long-term prognostic significance of 30-day readmission postdischarge of a 4-year cohort of elderly veterans first admitted to Medicare hospitals for treatment of hip fractures (HFx), controlling for comorbidities. DESIGN: Retrospective, national secondary data analysis. SETTING: National Medicare and Veterans Health Administration (VHA) facilities. PARTICIPANTS: The study cohort was 41,331 veterans with a HFx first admitted to a Medicare eligible facility during 1999 to 2002. MEASUREMENTS: HFxs were linked with all other Medicare and VHA inpatient discharge files to capture dual inpatient use. Logistic regression was used to examine the relationship between 30-day readmission and age, sex, inpatient length of stay, and selected Elixhauser comorbidities. RESULTS: Approximately 18.3% (7,579/41,331) of HFx patients were readmitted within 30 days. Of those with 30-day readmissions, 48.5% (3,675/7,579) died within 1 year, compared with 24.9% (8,388/33,752) of those without 30-day readmissions. Readmission risk was significantly greater in the presence of specific comorbidities, ranging from 11% greater risk for patients with fluid and electrolyte disorders (95% confidence interval (CI)=1.04-1.20) to 43% for renal failure (95% CI=1.29-1.60). For this cohort, cardiac arrhythmias (24%), chronic pulmonary disease (28%), and congestive heart failure (16%) were common comorbidities, and all affected the risk of 30-day readmission. CONCLUSION: Patients with HFx with 30-day readmissions were nearly twice as likely to die within 1 year. Identification of several predictive comorbidities at discharge and examination of reasons for subsequent readmission suggests that readmission was largely due to active comorbid clinical problems. These comorbidity findings have implications for the current Centers for Medicare and Medicaid Services (CMS) pay-for-performance initiatives, especially those related to better coordination of care for patients with chronic illnesses. These comorbidity findings for elderly patients with HFx may also provide data to enable CMS and healthcare providers to more accurately differentiate between comorbidities and hospital-acquired complications under the current CMS initiative related to nonpayment for certain types of medical conditions and hospital acquired infections.

Health care costs for patients with chronic spinal cord injury in the Veterans Health Administration.

BACKGROUND/OBJECTIVE: Recurring annual costs of caring for patients with chronic spinal cord injury (SCI) is a large economic burden on health care systems, but information on costs of SCI care beyond the acute and initial postacute phase is sparse. The objective of this study was to establish a frame of reference and estimate of the annual direct medical costs associated with health care for a sample of patients with chronic SCI (ie, > 2 years after injury). METHODS: Patients were recruited from 3 Veterans Health Administration (VHA) SCI facilities; baseline patient information was cross-referenced to the Decision Support System (DSS) National Data Extracts (NDE) to obtain patient-specific health care costs in VHA. Descriptive statistical analysis of annual DSS-NDE cost of patients with SCI (N = 675) for fiscal year (FY) 2005 by level and completeness of injury was conducted. RESULTS: Total (inpatient and outpatient) annual (FY 2005) direct medical costs for 675 patients with SCI exceeded $14.47 million or $21,450 per patient. Average annual total costs varied from $28,334 for cervical complete SCI to $16,792 for thoracic incomplete SCI. Two hundred thirty-three of the 675 patients with SCI who were hospitalized over the study period accounted for a total of 378 hospital discharges, costing in excess of $7.19 million. This approximated a cost of outpatient care received of $7.28 million for our entire sample. CONCLUSIONS: The comprehensive nature of health care delivery and related cost capture for people with chronic SCI in the VHA provided us the opportunity to accurately determine health care costs for this population. Future SCI postacute care cost analyses should consider case-mix adjusting patients at high risk for rehospitalization.

Drug costs and use in VHA nursing homes: a national overview of long-stay residents.

OBJECTIVES: The aim of this study was to provide national annualized estimates of drug costs and use by drug classes for long-stay nursing home (NH) residents. DESIGN: National, descriptive, secondary data analysis. SETTING: National, Veterans Health Administration (VHA), 136 NHs. PARTICIPANTS: Our study population consisted of 6554 VHA long-stay NH residents, identified from the Minimum Data Set (MDS), who had an annual assessment during FY 2005 linked with 8,847,561 inpatient pharmacy claims. MEASUREMENT: Descriptive statistics of the annual drug costs and use by VHA therapeutic drug classes obtained from FY 2005 national pharmacy claims linked at the individual resident level. RESULTS: The total cost of the drugs was $23,782,717 in 326 drug classes for 6554 VHA NH residents. Average annual drug cost was $3629 per resident (99% Confidence Interval [CI], $3343-$3915). The top 20 drug classes accounted for nearly 70% of total drug costs for long-stay NH residents. Approximately three quarters (73.3%) of these residents received a non-opioid analgesic (eg, acetaminophen, aspirin). Over half of these residents received antidepressants (selective serotonin reuptake inhibitors [SSRIs]) (54.3%), or other anti-infective drugs (eg, bacitracin, ciprofloxacin) (53.3%). CONCLUSIONS: This is the first national study of drug costs and use for long-stay veterans in VHA NHs. It is essential in any study analyzing drug costs and use in NH patients to differentiate long-stay residents from short-stay patients. This kind of detailed cost and use analysis has implications for projecting future costs associated with the Medicare Part D prescription benefit for dually eligible NH residents.