Association between Medicare Advantage plan star ratings and enrollment

Comprehensive Medication Review Completion Rates and Disparities After Medicare Star Rating Measure

Importance

Comprehensive medication reviews (CMRs) are offered to qualifying US Medicare beneficiaries annually to optimize medication regimens and therapeutic outcomes. In 2016, Medicare adopted CMR completion as a Star Rating quality measure to encourage the use of CMRs.

Objective

To examine trends in CMR completion rates before and after 2016 and whether racial, ethnic, and socioeconomic disparities in CMR completion changed.

Design, Setting, and Participants

This observational study using interrupted time-series analysis examined 2013 to 2020 annual cohorts of community-dwelling Medicare beneficiaries aged 66 years and older eligible for a CMR as determined by Part D plans and by objective minimum eligibility criteria. Data analysis was conducted from September 2022 to February 2024.

Exposure

Adoption of CMR completion as a Star Rating quality measure in 2016.

Main Outcome and Measures

CMR completion modeled via generalized estimating equations.

Results

The study included a total of 561 950 eligible beneficiaries, with 253 561 in the 2013 to 2015 cohort (median [IQR] age, 75.8 [70.7-82.1] years; 90 778 male [35.8%]; 6795 Asian [2.7%]; 24 425 Black [9.6%]; 7674 Hispanic [3.0%]; 208 621 White [82.3%]) and 308 389 in the 2016 to 2020 cohort (median [IQR] age, 75.1 [70.4-80.9] years; 126 730 male [41.1%]; 8922 Asian [2.9%]; 27 915 Black [9.1%]; 7635 Hispanic [2.5%]; 252 781 White [82.0%]). The unadjusted CMR completion rate increased from 10.2% (7379 of 72 225 individuals) in 2013 to 15.6% (14 185 of 90 847 individuals) in 2015 and increased further to 35.8% (18 376 of 51 386 individuals) in 2020, in part because the population deemed by Part D plans to be MTM-eligible decreased by nearly half after 2015 (90 487 individuals in 2015 to 51 386 individuals in 2020). Among a simulated cohort based on Medicare minimum eligibility thresholds, the unadjusted CMR completion rate increased but to a lesser extent, from 4.4% in 2013 to 12.6% in 2020. Compared with White beneficiaries, Asian and Hispanic beneficiaries experienced greater increases in likelihood of CMR completion after 2016 but remained less likely to complete a CMR. Dual-Medicaid enrollees also experienced greater increases in likelihood of CMR completion as compared with those without either designation, but still remained less likely to complete CMR.

Conclusion and Relevance

This study found that adoption of CMR completion as a Star Rating quality measure was associated with higher CMR completion rates. The increase in CMR completion rates was achieved partly because Part D plans used stricter eligibility criteria to define eligible patients. Reductions in disparities for eligible Asian, Hispanic, and dual-Medicaid enrollees were seen, but not eliminated. These findings suggest that quality measures can inform plan behavior and could be used to help address disparities.

Enrollment Patterns of Medicare Advantage Beneficiaries by Dental, Vision, and Hearing Benefits

Importance

Most Medicare beneficiaries now choose to enroll in Medicare Advantage (MA) plans. Racial and ethnic minority group and low-income beneficiaries are increasingly enrolling in MA plans.

Objective

To examine whether dental, vision, and hearing supplemental benefits offered in MA plans are associated with the plan choices of traditionally underserved Medicare beneficiaries.

Design, Setting, and Participants

This exploratory observational cross-sectional study used data from the 2018 to 2020 Medicare Current Beneficiary Survey linked to MA plan benefits. The nationally representative sample comprised primarily community-dwelling MA beneficiaries enrolled in general enrollment MA plans. Data analysis was performed between April and October 2023.

Exposures

Beneficiary self-identified race and ethnicity and combined individual and spouse income and educational attainment.

Main Outcomes and Measures

Binary indicators were developed to determine whether beneficiaries were enrolled in a plan offering any dental, comprehensive dental, any vision, eyewear, any hearing, or hearing aid benefit. Mixed-effects logistic regression models were estimated to report average marginal effects adjusted for beneficiary-level demographic and health characteristics, plan attributes, and plan availability.

Results

This study included 8139 (weighted N = 31 million) eligible MA beneficiaries, with a mean (SD) age of 77.7 (7.5) years. More than half of beneficiaries (54.9%) were women; 9.8% self-identified as Black, 2.0% as Hispanic, 83.9% as White, and 4.2% as other or multiple races or ethnicities. Plan choices by dental benefits were examined among 7516 beneficiaries who were not enrolled in any dental standalone plan, by vision benefits for 8026 beneficiaries not enrolled in any vision standalone plan, and by hearing benefits for 8131 beneficiaries not enrolled in any hearing standalone plan. Black beneficiaries were more likely to enroll in plans with any dental benefit (9.0 percentage points [95% CI, 3.4-14.4]; P < .001), any comprehensive dental benefit (11.2 percentage points [95% CI, 5.7-16.7]; P < .001), any eye benefit (3.0 percentage points [95% CI, 1.0 to 5.0]; P = .004), or any eyewear benefit (6.0 percentage points [95% CI, 0.6-11.5]; P = .03) compared with White beneficiaries. Lower-income individuals (earning ≤200% of the federal poverty level) were more likely to enroll in a plan with a comprehensive dental benefit (4.4 percentage-point difference [95% CI, 0.1-7.9]; P = .01) compared with higher-income beneficiaries. Beneficiaries without a college degree were more likely to enroll in a plan with a comprehensive dental benefit (4.7 percentage-point difference [95% CI, 1.4-8.0]; P = .005) compared with those with higher educational attainment.

Conclusions and Relevance

The results of this study suggest that racial and ethnic minority individuals and those with lower income or educational attainment are more likely to choose MA plans with dental or vision benefits. As the federal government prepares to adjust MA plan star ratings for health equity, implements MA payment cuts, and allows increasing flexibility in supplemental benefit offerings, these findings may inform benefit monitoring for MA.

Legislative and Regulatory Options for Improving Medicare Advantage

The Medicare Advantage program was created to expand beneficiary choice and to reduce spending through capitated payment to private insurers. However, many stakeholders now argue that Medicare Advantage is failing to deliver on its promise to reduce spending. Three problematic design features in Medicare Advantage payment policy have received particular scrutiny: (1) how baseline payments to insurers are determined, (2) how variation in patient risk affects insurer payment, and (3) how payments to insurers are adjusted for quality performance. The authors analyze the statute underlying these three design features and explore legislative and regulatory strategies for improving Medicare Advantage. They conclude that regulatory approaches for improving risk adjustment and for recouping overpayments from risk-score gaming have the highest potential impact and are the most feasible improvement measures to implement.

Impact of star ratings on Medicare health plan enrollment: A systematic literature review

BACKGROUND

The Medicare star ratings program was developed by the Centers for Medicare and Medicaid Services in 2007 as an approach to evaluate health plan performance and quality.

OBJECTIVE

This study aimed to identify and narratively describe studies that attempted to quantitatively assess the impact that Medicare star ratings have on health plan enrollment.

METHODS

A systematic literature review (SLR) was conducted of PubMed MEDLINE, Embase, and Google to identify articles that quantitatively assessed the impact of Medicare star ratings on health plan enrollment. Inclusion criteria consisted of studies that conducted quantitative analyses to estimate the potential impact. Exclusion criteria consisted of qualitative studies and studies that did not directly assess plan enrollment.

RESULTS

This SLR identified 10 studies that sought to measure the impact of Medicare star ratings on plan enrollment. Nine of the studies found that plan enrollment increased in accordance with increases in star ratings or that plan disenrollment increased with decreases in star ratings. One study conducted of data before the implementation of the Medicare quality bonus payment found contradictory results from one year to the next, whereas all the studies that assessed data after implementation found increases in enrollment in accordance to increases in star ratings or increases in disenrollment for decreases in star ratings. One concerning finding from some of the articles included in the SLR is that increases in star ratings had less of an impact on enrollment in higher-rated plans for ethnic and racial minorities and older adults.

CONCLUSIONS

Increases in Medicare star ratings led to statistically significant increases in health plan enrollment and decreases in health plan disenrollment. Future studies are needed to assess whether this increase has a causal association or is caused by additional factors outside of or in addition to increases in overall star rating.

Solving racial/ethnic disparities associated with Medicare Part D Star Ratings

OBJECTIVE

Medicare Part D Star Ratings are instrumental in shaping healthcare quality improvement efforts. However, the calculation metrics for medication performance measures for this program have been associated with racial/ethnic disparities. In this study, we aimed to explore whether an alternative program, named Star Plus by us that included all medication performance measures developed by Pharmacy Quality Alliance and applicable to our study population, would reduce such disparities among Medicare beneficiaries with diabetes, hypertension, and/or hyperlipidemia.

METHOD

We conducted an analysis of a 10% random sample of Medicare A/B/D claims linked to the Area Health Resources File. Multivariate logistic regressions with minority dummy variables were used to examine racial/ethnic disparities in measure calculations of Star Ratings and Star Plus, respectively.

RESULTS

Adjusted results indicated that relative to non-Hispanic Whites (Whites), racial/ethnic minorities had significantly lower odds of being included in the Star Ratings measure calculations: the odds ratios (ORs) for Blacks, Hispanics, Asians, and Others were 0.68 (95% confidence interval [CI] = 0.66-0.71), 0.73 (CI = 0.69-0.78), 0.88 (CI = 0.82-0.93), and 0.92 (CI = 0.88-0.97), respectively. In contrast, every beneficiary in the sample was included in Star Plus. Further, racial/ethnic minorities had significantly higher increase in the odds of being included in measure calculation in Star Plus than Star Ratings. The ORs for Blacks, Hispanics, Asians, and Others were 1.47 (CI = 1.41-1.52), 1.37 (CI = 1.29-1.45), 1.14 (CI = 1.07-1.22), and 1.09 (CI = 1.03-1.14), respectively.

CONCLUSIONS

Our study demonstrated that racial/ethnic disparities may be eliminated by including additional medication performance measures to Star Ratings.

Racial and ethnic disparities in the enrolment of medicare medication therapy management programs

Objectives

Racial/ethnic disparities have been found in prior literature examining enrolment in Medicare medication therapy management programs. However, those studies were based on various eligibility scenarios because enrolment data were unavailable. This study tested for potential disparities in enrolment using actual MTM enrolment data.

Methods

Medicare Parts A&B claims, Medication Therapy Management Data Files, and the Area Health Resources File from 2013 to 2014 and 2016 to 2017 were analysed in this retrospective analysis. An adjusted logistic regression compared odds of enrolment between racial/ethnic minorities and non-Hispanic Whites (Whites) in the total sample and subpopulations with diabetes, hypertension, or hyperlipidaemia. Trends in disparities were analysed by including interaction terms in regressions between dummy variables for race/ethnic minority groups and period 2016-2017.

Key Findings

Disparities in MTM enrolment were detected between Blacks and Whites with diabetes in 2013-2014 (Odds Ratio = 0.78, 95% Confidence Interval = 0.75-0.81). This disparity improved from 2013-2014 to 2016-2017 for Blacks (Odds Ratio=1.08, 95% Confidence Interval = 1.04-1.11) but persisted in 2016-2017 (Odds Ratio = 0.84, 95% Confidence Interval = 0.81-0.87). A disparity was identified between Blacks and Whites with hypertension in 2013-2014 (Odds Ratio = 0.92, 95% Confidence Interval = 0.89-0.95) but not in 2016-2017. Enrolment for all groups, however, declined between periods. For example, in the total sample, the odds of enrolment declined from 2013-2014 to 2016-2017 by 22% (Odds Ratio=0.78, 95% Confidence Interval=0.75-0.81).

Conclusions

Racial disparities in MTM enrolment were found between Blacks and Whites among Medicare beneficiaries with diabetes in both periods and among individuals with hypertension in 2013-2014. As overall enrolment fell between periods, concerns about program enrolment remain.

Impact of Public Reporting of Center-Specific Survival Analysis Scores on Patient Volumes at Hematopoietic Cell Transplant Centers

BACKGROUND

The Center for International Blood and Marrow Transplant Research (CIBMTR) reports the outcomes of allogeneic hematopoietic cell transplantation (alloHCT) at United States transplant centers (TC) annually through its Center-Specific Survival Analysis (CSA). The CSA compares the actual 1-year overall survival (OS) and predicted 1-year OS rate after alloHCT at each TC, which is then reported as 0 (OS as expected), -1 (OS worse than expected), or +1 (OS better than expected).

OBJECTIVE

We evaluated the impact of public reporting of TC performance on their alloHCT patient volumes.

STUDY DESIGN

Ninety-one TCs that serve adult or combined adult and pediatric populations and had CSA scores reported for 2012-2018 were included. We analyzed prior-calendar year TC volume, prior-calendar year CSA score, whether the CSA score had changed in the prior year from two years earlier, calendar year, TC type (adult only vs. combined adult and pediatric), and years of alloHCT experience for their impact on patient volumes.

RESULTS

A CSA score of -1, as compared with 0 or +1, was associated with an 8%-9% reduction in the mean TC volume (P < 0.001) in the subsequent year, adjusting for the prior year center volume. Additionally, being a TC neighboring an index TC with a -1 CSA score, was associated with a 3.5% increase in mean TC volume (P = 0.04).

CONCLUSION

Our data show that public reporting of CSA scores is associated with changes in alloHCT volumes at TCs. Additional investigation into the causes of this shift in patient volume and the impact on outcomes is ongoing.

Racial and ethnic disparities in access to and enrollment in high-quality Medicare Advantage plans

OBJECTIVE

Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower-quality plans, measured by a 5-star quality rating system. We examine whether differential access to high-rated plans was associated with this differential enrollment in high-rated plans by race and ethnicity among MA enrollees.

DATA SOURCES

The Medicare Master Beneficiary Summary File and MA Landscape File for 2016.

STUDY DESIGN

We first examined county-level MA plan offerings by race and ethnicity. We then examined the association of racial and ethnic differences in enrollment by star rating by controlling for the following different sets of covariates: (1) individual-level characteristics only, and (2) individual-level characteristics and county-level MA plan offerings.

DATA COLLECTION/EXTRACTION METHODS

Not applicable PRINCIPAL FINDINGS: Racial and ethnic minority enrollees had, on average, more MA plans available in their counties of residence compared to White enrollees (16.1, 20.8, 20.2, vs. 15.1 for Black, Asian/Pacific Islander, Hispanic, and White enrollees), but had fewer number of high-rated plans (4-star plans or higher) and/or more number of low-rated plans (3.5-star plans or lower). While racial and ethnic minority enrollees had lower enrollment in 4-4.5 star plans than White enrollees, this difference substantially decreased after accounting for county-level MA plan offerings (-9.1 to -0.5 percentage points for Black enrollees, -15.9 to -5.0 percentage points for Asian/Pacific Islander enrollees, and -12.7 to 0.6 percentage points for Hispanic enrollees). Results for Black enrollees were notable as the racial difference reversed when we limited the analysis to those who live in counties that offer a 5-star plan. After accounting for county-level MA plan offerings, Black enrollees had 3.2 percentage points higher enrollment in 5-star plans than White enrollees.

CONCLUSIONS

Differences in enrollment in high-rated MA plans by race and ethnicity may be explained by limited access and not by individual characteristics or enrollment decisions.

Effects of Part D Star Ratings on racial and ethnic disparities in health care costs

Background

Racial/ethnic minorities are less likely than non-Hispanic White (White) patients to be included in the Medicare Part D Star Ratings measure assessment due to the restrictive inclusion criteria for the measures.

Objective

This paper examined the effects of racial/ethnic disparities in the measure assessment in Part D Star Ratings on disparities in healthcare costs among patients with Alzheimer's disease and related dementias (ADRD).

Methods

This cross-sectional study analyzed 2017 Medicare data. Proportions of Beneficiaries with ADRD were categorized into the included and excluded groups based on the inclusion criteria for the calculation of medication adherence measures in Star Ratings. Outcomes included costs for medications, physician visits, emergency room (ER) visits, and total costs. A generalized linear model was employed to compare costs across racial/ethnic groups. To explore the differential disparities in healthcare costs between the 2 groups, interaction terms between dummy variables for being excluded from the measure calculation and racial/ethnic minorities were included in the models.

Results

The patterns of racial/ethnic disparities in healthcare costs found in this study were generally consistent with expectations, with some exceptions. For example, compared with White patients, in the hyperlipidemia cohort, the physician visit cost for Black patients among the included group was 31% lower (cost ratio or CR = 0.69, 95% CI = 0.67-0.72); in the hypertension cohort, the hospitalization cost for Blacks among the excluded group was 15% higher (CR = 1.15, 95% CI = 1.12-1.19). More importantly, exclusion from measurement assessments was associated with differential cost disparities. For example, compared with individuals included in the measure assessment for hypertension, the Black-White disparities in costs for hospitalization and total healthcare were 30% higher (CR = 1.30, 95% CI = 1.26-1.34), and 10% higher (CR = 1.10; 95% CI = 1.08-1.12), respectively, among the excluded group.

Conclusions

Medicare Part D Star Ratings may be associated with aggravated racial/ethnic disparities in healthcare costs in the Medicare Part D population.

A digital divide in the COVID-19 pandemic: information exchange among older Medicare beneficiaries and stakeholders during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic resulted in unprecedented challenges for older adults. Medicare enrollment was already an overwhelming process for a high fraction of older adults pre-pandemic. Therefore, the purpose of this qualitative study was to gain understanding from community organizations and stakeholders about their pre-pandemic and during-pandemic experiences while adapting to continue offering insurance advice to seniors, what resources are available to seniors, and what needs to be done to help seniors make higher quality insurance choices in the Medicare program. In addition, we wanted to explore how the COVID-19 pandemic may have changed the ways that these stakeholders interacted with Medicare beneficiaries.

METHODS

We employed a qualitative strategy to gain a deep understanding of the challenges that these organizations may have faced while offering advice/counseling to older adults. We accomplished this by interviewing a group of 30 stakeholders from different states.

RESULTS

Every stakeholder mentioned that some older adults have difficulty making Medicare decisions, and 16 stakeholders mentioned that their system is complex and/or overwhelming for older adults. Twenty-three stakeholders mentioned that Medicare beneficiaries are often confused about Medicare, and this is more noticeable among new enrollees. With the onset of the pandemic, 22 of these organizations mentioned that they had to move to a virtual model in order to assist beneficiaries, especially at the beginning of the pandemic. However, older adults seeking advice/meetings have a strong preference for in-person meetings even during the pandemic. Given that the majority of the beneficiaries that these stakeholders serve may not have access to technology, it was difficult for some of them to smoothly transition to a virtual environment. With Medicare counseling moving to virtual or telephone methods, stakeholders discussed that many beneficiaries had difficulty utilizing these options in a variety of ways.

CONCLUSIONS

Findings from our interviews with stakeholders provided information regarding experiences providing Medicare counseling pre- and during-COVID-19 pandemic. Some of the barriers faced by older adults included a complex and overwhelming system, a strong preference for in-person meetings among beneficiaries, challenges with technology, and an increased risk of information overload and misinformation. While bias may exist within the study and sample, given that technology-savvy beneficiaries may not seek help from organizations our study participants work in, they show how the current Medicare system may impact vulnerable older adults who may need support with access to high-speed internet and digital literacy.

Impact of an educational program and decision tool on choice of maternity hospital: the delivery decisions randomized clinical trial

Background

Reducing cesarean rates is a public health priority. To help pregnant people select hospitals with lower cesarean rates, numerous organizations publish publically hospital cesarean rate data. Few pregnant people use these data when deciding where to deliver. We sought to determine whether making cesarean rate data more accessible and understandable increases the likelihood of pregnant people selecting low-cesarean rate hospitals.

Methods

We conducted a 1:1 randomized controlled trial in 2019–2021 among users of a fertility and pregnancy mobile application. Eligible participants were trying to conceive for fewer than five months or were 28–104 days into their pregnancies. Of 189,456 participants approached and enrolled, 120,621 participants met entry criteria and were included in analyses. The intervention group was offered an educational program explaining the importance of hospital cesarean rates and an interactive tool presenting hospital cesarean rates as 1-to-5-star ratings. Control group users were offered an educational program about hospital choice and a hospital choice tool without cesarean rate data. The primary outcome was the star rating of the hospital selected by each patient during pregnancy. Secondary outcomes were the importance of cesarean rates in choosing a hospital and delivery method (post-hoc secondary outcome).

Results

Of 120,621 participants (mean [SD] age, 27.8 [7.9]), 12,284 (10.2%) reported their choice of hospital during pregnancy, with similar reporting rates in the intervention and control groups. Intervention group participants selected hospitals with higher star ratings (2.52 vs 2.16; difference, 0.37 [95% CI, 0.32 to 0.43] p < 0.001) and were more likely to believe that the hospitals they chose would impact their chances of having cesarean deliveries (38.5% vs 33.1%, p < 0.001) but did not assign higher priority to cesarean delivery rates when choosing their hospitals (76.2% vs 74.3%, p = 0.05). There was no difference in self-reported cesarean rates between the intervention and control groups (31.4% vs 31.4%, p = 0.98).

Conclusion

People offered an educational program and interactive tool to compare hospital cesarean rates were more likely to use cesarean data in selecting a hospital and selected hospitals with lower cesarean rates but were not less likely to have a cesarean.

Clinical Trial Registration

Registered December 9, 2016 at clinicaltrials.gov, First enrollment November 2019. ID NCT02987803, https://clinicaltrials.gov/ct2/show/NCT02987803

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05087-y.

Evolution of the Comprehensive Medication Review Completion Rate for Medicare Part D Plans: What Do the Stars Tell Us?

Objective To describe changes in the Medicare Part D Comprehensive Medication Review (CMR) completion rate within the Centers for Medicare & Medicaid Services (CMS) Star Ratings program since its inception. Methods Publicly available information for Star Ratings years 2014 to 2021 was obtained from the CMS website and through indexed literature and internet searches. Data elements for the CMR completion measure were extracted for Medicare Advantage prescription drug plans (MA-PDs) and prescription drug plans (PDPs) and included the annual weighted value, cut-points for star rating, completion rates, and star achievement. Results In 2014 and 2015, the CMR completion rate was a display measure in the Star Ratings program with rates between 10 and 16%. This measure was added in 2016 with a weighted value of 1 that has remained the same. The cut-points when comparing 2016 with 2021 have increased from less than 13.6 to less than 48% for 1 star and 76 to 89% or more for 5 stars for MA-PDs and from less than 8.5 to less than 24% for 1 star and 36.7 to 61% or more for 5 stars for PDPs. From 2016 to 2021, the average Star Ratings for CMR completion increased from 2.3 to 3.7 for MA-PDs and 2.3 to 3.6 for PDPs. Conclusion Since the inception of the CMR completion rate as a quality measure, an increasing proportion of eligible beneficiaries has received a CMR with MA-PDs consistently providing this service to more beneficiaries than PDPs. The cut-points for star achievement have also risen, requiring higher CMR completion rates to achieve higher star ratings. Further evolution of the CMR quality measure is needed for improving medication management.

Racial and ethnic disparities due to Medicare Part D Star Ratings criteria among kidney transplant patients with diabetes, hypertension, and/or dyslipidemia

BACKGROUND: Policies such as Medicare Part D Star Ratings are designed to encourage medication adherence and facilitate positive health outcomes. Patients who have received a kidney transplant not included in assessment of Star Ratings measures may have worse outcomes. OBJECTIVE: To determine if criteria for inclusion in assessment of Star Ratings medication adherence measures among kidney transplant patients with diabetes, hypertension, and dyslipidemia lead to racial and ethnic disparities in who is included in this assessment. METHODS: This was a cross-sectional, secondary analysis of 94,822 adult kidney transplant patients receiving continuous coverage of Medicare Parts A/B/D and filling at least 1 prescription for diabetes, hypertension, or dyslipidemia in 2017. Utilizing 2017 Medicare claims, inclusion in assessment of Star Ratings measures was determined based on criteria for each measure concerning adherence to oral diabetes, hypertension, and dyslipidemia medication. Binary and multinomial logistic regression were conducted. RESULTS: Among kidney transplant patients with diabetes only, Black and Hispanic patients were less likely than White patients to be included in assessment of the Star Ratings adherence measure for oral diabetes medications (P < 0.0001). Among kidney transplant patients with hypertension only and dyslipidemia only, all racial and ethnic minority groups were less likely to be included in assessments of Star Ratings adherence measures for oral hypertension and dyslipidemia medications (P < 0.001). For example, among patients with hypertension, adjusted odds ratios for inclusion of Black, Hispanic, and Asian patients were 0.44 (95% CI = 0.40-0.49), 0.56 (95% CI = 0.49-0.63), and 0.55 (95% = CI 0.45-0.67), respectively. CONCLUSIONS: Disparities exist among patients who have received a kidney transplant qualifying for inclusion in Star Ratings measures, which may ultimately facilitate adverse health outcomes. DISCLOSURES: Marie Chisholm-Burns is a member of the American Society of Transplantation Board of Directors. Christina Spivey has no conflicts of interest to disclose. Chi Chun Tsang has no conflicts of interest to disclose. Junling Wang received funding for this project from the National Institute on Aging/National Institutes of Health; she has also received funding from AbbVie and Pharmaceutical Research and Manufacturers of America (additionally, she has received consulting fees from the latter). Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG049696 (Principal Investigator: Junling Wang). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The sponsor of the research does not have any role in any aspect of the research, including study design and the collection, analysis, and interpretation of data; the writing of the report; and the decision to submit the manuscript for publication.

Consumer selection and home health agency quality and patient experience stars

OBJECTIVE

To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection.

DATA SOURCES

We utilized 2014-2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website.

DATA COLLECTION/EXTRACTION METHODS

We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee-for-Service home health users.

STUDY DESIGN

This admission-level assessment compared HHA selection before (July 2014-June 2015) and after (February-December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs.

PRINCIPAL FINDINGS

The introduction of star ratings was associated with a 0.88-percentage-point increase in the probability of selecting a high-quality HHA and a 0.81-percentage-point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare-Medicaid dual-eligible beneficiaries experienced larger increases in their likelihood of selecting high-rated agencies than inpatient, white, and nondual beneficiaries.

CONCLUSIONS

The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection.

Association of Health Insurance Literacy With Enrollment in Traditional Medicare, Medicare Advantage, and Plan Characteristics Within Medicare Advantage

IMPORTANCE

Health insurance literacy helps individuals make informed choices. However, evidence suggests that Medicare beneficiaries experience low health insurance literacy, leading to high-cost or poor-quality coverage choices.

OBJECTIVE

To examine how health insurance literacy was associated with coverage choices between traditional Medicare (TM) and Medicare Advantage (MA), as well as within MA.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 6627 TM and MA enrollees, using data from the 2015-2016 Medicare Current Beneficiary Survey. Data analyses were conducted between May 1 and June 30, 2021.

EXPOSURES

Three self-reported measures of health insurance literacy (presence of information to make an informed comparison, ease in reviewing and comparing coverage options, and annual review and comparison of coverage options).

MAIN OUTCOMES AND MEASURES

Enrollment in TM vs MA and enrollment in an MA plan with different characteristics (star rating, monthly plan premium, in-network maximum out-of-pocket limit, plan type, and provision of supplemental benefits).

RESULTS

We included 6627 Medicare beneficiaries (3578 women [54.0%]; mean [SD] age, 75.13 [7.12] years). A total of 77 individuals were Asian (1.2%), 696 were Black (10.5%), 488 were Hispanic (7.4%), 5277 were non-Hispanic White (79.6%), and 225 (3.4%) were single races not of Hispanic origin (including American Indian or Alaska Native and Native Hawaiian) or were 2 or more races. Medicare Advantage enrollment was higher among individuals with higher health insurance literacy than those with lower health insurance literacy, especially for those who reviewed or compared coverage options annually than among those who did not (38.0%; 95% CI, 36.0%-40.1% vs 27.8%; 95% CI, 25.8%-29.7%). Among MA beneficiaries, those who reviewed or compared coverage options annually were more likely to enroll in plans with 4 to 4.5 stars and plans with monthly premiums of $1 to $50 by 4.6 percentage points (95% CI, 0.1-9.2 percentage points) and 4.8 percentage points (95% CI, 0.6-9.0 percentage points), respectively. However, enrollment in plans with 5 stars was 3.8 percentage points lower (95% CI, -5.8 to -1.9 percentage points) among individuals who reviewed or compared coverage options annually than among those who did not. Among individuals with low socioeconomic status, the likelihood of reviewing or comparing coverage options annually was lower for those with Medicare and Medicaid dual eligibility than for those without it (odds ratio, 0.79; 95% CI, 0.63-0.99).

CONCLUSIONS AND RELEVANCE

Results of this study suggest that higher health insurance literacy-particularly, annual review and comparison of coverage choices-is associated with higher MA enrollment and choice of a particular MA plan. Policy makers should develop programs to encourage frequent review and comparison of coverage options for informed decision making.

The Medicare Advantage Quality Bonus Program Has Not Improved Plan Quality

In 2012 Medicare introduced the quality bonus program, linking financial bonuses to commercial insurers' quality performance in Medicare Advantage (MA). Despite large investments in the program, evidence of its effectiveness is limited. We analyzed insurance claims from the period 2009-2018 from the nation's largest MA claims database for 3,753,117 MA beneficiaries (treatment group) and 4,025,179 commercial enrollees (control group). Using a difference-in-differences framework, we evaluated changes in performance on nine claims-based measures of quality in both groups before and after the start of the bonus program and with adjustment for differential pre-period trends. We observed no consistent differential improvement in quality for MA versus commercial enrollees under the quality bonus program. Program participation was associated with significant quality improvements among MA beneficiaries on four measures, significant declines on four other measures, and no significant change in overall quality performance (+0.6 percentage points). Together, these results suggest that the quality bonus program did not produce the intended improvement in overall quality performance of MA plans.

The Relationship Between Medicare Advantage Star Ratings and Enrollee Experience

BACKGROUND

Medicare Advantage plans, private managed care plans that enrolled 34% of Medicare beneficiaries in 2019, received $6 billion in annual bonus payments on the basis of their performance on a 5-star rating system. Little is known, however, as to the extent these ratings adequately capture enrollee experience.

OBJECTIVES

To measure the effect of exposure to higher rated Medicare Advantage contracts on enrollee experience.

DESIGN

An instrumental variables analysis using MA contract consolidation as an exogenous shock to the quality of plan enrollees are exposed to.

PARTICIPANTS

A total of 345,897 MA enrollees enrolled in non-consolidated contracts and 21,405 enrollees who were consolidated.

MAIN MEASURES

The primary exposure was enrollee star rating, instrumented using contract consolidation. The primary outcomes were enrollee self-reported experience measures.

KEY RESULTS

There were no significant effects on increased star ratings on 23 of 27 outcomes. A one-star increase in contract star rating leads to a 5.4 percentage point increase in reporting that pain does not interfere with daily activities (95%CI 2.4, 8.4), and a 4.4 percentage reduction in the likelihood that a physician would talk to the enrollee about physical activity (95%CI: -7.8, -1.1, all p<0.05). A one-star increase in contract star rating led to an 8.4 percentage point reduction in achieving the top score on the received needed information index (95%CI: -16.4, -0.4), and a 1.8 percentage point reduction in responding with the lowest score for the overall rating of care (95%CI: -3.5, -0.1).

CONCLUSIONS

Exposure to a higher rated MA contract did not appreciably increase enrollee experience. Policymakers should consider reassessing how these ratings and associated bonus payments are currently calculated.

A conceptual framework for evaluation of community pharmacy pay-for-performance programs

BACKGROUND

Recent interest in initiating pay-for-performance (P4P) programs indicates an underlying belief that economic incentives will have a direct impact on health care quality and efficiency. Evaluations of the impact of P4P programs on health care organizations and providers have been presented in the literature; however, none have focused on the impact of an incentive targeting community pharmacies.

OBJECTIVE

To propose a theory-derived conceptual framework of how a financial incentive might work in a community pharmacy.

METHODS

Studies from the fields of economics (agency theory), psychology (intrinsic and extrinsic motivators; expectancy theory), and organizational theory (ownership, institutional layers, organizational culture, and change management; quality improvement) were reviewed to inform the framework's components. This proposed conceptual framework also integrated and expanded on previous health care-related P4P models.

RESULTS

P4P programs inherently use financial incentives to catalyze change; however, elements from psychology and organizational theories along with economic theory were identified as important considerations in how a financial incentive may operate when targeting a community pharmacy. Through the incorporation of these theories along with other P4P frameworks in health care, a conceptual framework was derived comprising 4 domains: incentive, pharmacy, other influencing factors, and P4P program measures. Hypothesized relationships among these domains were depicted.

CONCLUSION

As focus on improving the quality of health care provision develops, opportunities for pharmacists to provide patient care services beyond dispensing will continue to advance, along with expanded reimbursement mechanisms extending beyond traditional product dispensing. The proposed theory-derived conceptual framework serves to depict how the integration of P4P and other factors may affect the pharmacy environment and subsequently affect a pharmacy's capability to perform well on medication-related quality measures. This framework may be used as a foundation on which to design studies to investigate the association between community pharmacy factors and performance in a P4P program.

Incentivizing Excellent Care to At-Risk Groups with a Health Equity Summary Score

BACKGROUND

Social risk factors (SRFs) such as minority race-and-ethnicity or low income are associated with quality-of-care, health, and healthcare outcomes. Organizations might prioritize improving care for easier-to-treat groups over those with SRFs, but measuring, reporting, and further incentivizing quality-of-care for SRF groups may improve their care.

OBJECTIVE

To develop, as a proof-of-concept, a Health Equity Summary Score (HESS): a succinct, easy-to-understand score that could be used to promote high-quality care to those with SRFs in Medicare Advantage (MA) health plans, which provide care for almost twenty million older and disabled Americans and collect extensive quality measure and SRF data.

DESIGN

We estimated, standardized, and combined performance scores for two sets of quality measures for enrollees in 2013-2016 MA health plans, considering both current levels of care, within-plan improvement, and nationally benchmarked improvement for those with SRFs (specifically, racial-and-ethnic minority status and dual-eligibility for Medicare and Medicaid).

PARTICIPANTS

All MA plans with publicly reported quality scores and 500 or more 2016 enrollees.

MAIN MEASURES

Publicly reported clinical quality and patient experience measures.

KEY RESULTS

Almost 90% of plans measured for MA Star Ratings received a HESS; plans serving few patients with SRFs were excluded. The summary score was moderately positively correlated with publicly reported overall Star Ratings (r = 0.66-0.67). High-scoring plans typically had sizable enrollment of both racial-and-ethnic minorities (38-42%) and dually eligible beneficiaries (29-38%).

CONCLUSIONS

We demonstrated the feasibility of developing and estimating a HESS that is intended to promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible MA enrollees. The HESS measures SRF-specific performance and does not simply duplicate overall plan Star Ratings. It also identifies plans that provide excellent care to large numbers of those with SRFs. Our methodology could be extended to other SRFs, quality measures, and settings.

Plan switching among Medicare Advantage beneficiaries with Alzheimer's disease and other dementias

INTRODUCTION

Patients with Alzheimer's disease and related dementias (ADRD) face substantial challenges in selecting, and remaining enrolled in, health insurance. Little is known about how patients with ADRD experience the Medicare Advantage (MA) program.

METHODS

We used, hospital, outpatient, and post-acute care data to identify MA beneficiaries with and without ADRD in 2014. Multinomial logit models estimated the percentage of people who disenrolled to traditional Medicare (TM) or switched to a different MA plan in 2015.

RESULTS

Among non-dually eligible beneficiaries, 9.0% (95% confidence interval [CI]: 8.0, 9.1) with ADRD disenrolled while 19.7% (95% CI: 19.6, 19.9) switched plans within MA compared to a disenrollment rate of 4.2% (95% CI: 4.2, 4.2) and switching rate of 22.8% (95% CI: 22.9, 22.8) for persons without ADRD.

DISCUSSION

MA enrollees with ADRD tend to disenroll at substantially higher rates than those without ADRD. This may be indicative of their care needs not being met in the program.

Is it time to replace the star ratings adherence measures?

Measures of medication adherence to noninsulin diabetes medications (NIDM), statins, and renin angiotensin system antagonists (RASA) have been continuously used in the star ratings program since 2012. Adherence to these treatments is undoubtedly important. However, the consistent use of these measures in the star ratings program over time has limitations. The purpose of this Viewpoints article is to highlight concerns associated with the current star ratings adherence measures and to offer proposals for the improvement of the adherence measurement in the program. This scoping review outlines concerns with the validity of the 3 star ratings adherence measures. In addition, star ratings data are used to describe payment thresholds for the 3 adherence measures over time to describe concerns associated with their use. Since 2012, there has been significant growth in the proportion of patients considered adherent in the star ratings program. Rates of adherence in a 2-star plan for NIDM (79%), RASA agents (83%), and statins (79%) now exceed what is commonly reported in the clinical literature. For a plan to achieve a rating of 5 stars, more than 88% of patients must be adherent to each measure. These rates suggest a ceiling effect and a reduced ability to distinguish plan performance. In addition, concerns over the potential for plans to "game" these measures have been raised. The use of mail order services, 90-day prescription refill programs, and automatic refill reminders all improve the proportion of days covered measurement but may not reflect true adherence improvements. Given potential concerns associated with the use of the existing adherence measures, it may be time to consider their replacement. One option would be to adopt a broader inventory of chronic medications to measure adherence in the program and to rotate medication categories in the program each year. It might also be time to explore measuring patient adherence to all medications that a patient uses instead of the narrow focus on the 3 existing measures. DISCLOSURES: No funding supported the writing of this article. Farley has nothing to disclose. Urick reports consulting fees from Pharmacy Quality Solutions, unrelated to this work.

Higher Medicare Advantage Star Ratings Are Associated With Improvements In Patient Outcomes

Little is known about how well the Centers for Medicare and Medicaid Services' five-star rating system for the overall quality of Medicare Advantage (MA) contracts captures quality of care. Leveraging contract consolidation as a natural experiment to study the association between outcomes and insurer-initiated enrollee shifts to plans with higher-rated contracts, we found that enrollees experiencing a one-star MA rating increase were 20.8 percent less likely to voluntarily leave their plan to enroll in another plan or traditional Medicare. When hospitalized, they were 3.4 percent more likely to use a higher-quality hospital and 2.6 percent less likely to be readmitted within ninety days. Our findings suggest that MA star ratings may capture key domains of an MA plan's quality; however, the differences in outcomes that they capture might not all be clinically meaningful.

Racial/ethnic disparities in measure calculations for Part D Star Ratings among Medicare beneficiaries with diabetes, hypertension, and/or hyperlipidemia

BACKGROUND

Previous literature reported racial/ethnic disparities in the measure assessment of diabetes medication adherence in the Medicare Part D Star Ratings program.

OBJECTIVE

This study examined the likelihood of inclusion in measure calculation across racial/ethnic groups for adherence metrics in Part D Star Ratings among individuals with diabetes, hypertension, and/or hyperlipidemia.

METHODS

This was a retrospective cross sectional analysis of a 10% random sample of 2017 Medicare claims linked to Area Health Resources Files. Inclusion in measure calculation was determined based on inclusion/exclusion criteria in adherence metrics for adherence medications for diabetes, hypertension, and hyperlipidemia in Part D Star Ratings developed by the Pharmacy Quality Alliance. Logistic regression and multinomial logistic regression were used to adjust for patient/community characteristics.

RESULTS

The study sample size was 2 707 216. Compared to Non-Hispanic White (White) beneficiaries, minorities were more likely to be excluded from measure calculation among individuals with 1 condition. For example, among individuals with hypertension, compared to White individuals, the adjusted odds ratios for exclusion for Black, Hispanic, Asian/Pacific Islander and other individuals were 1.46 (95% confidence interval, or CI = 1.42-1.50), 1.38 (95% CI = 1.33-1.43), 1.28 (95% CI = 1.21-1.35), and 1.08 (95% CI = 1.02-1.15), respectively. Among individuals with more than 1 chronic condition, minorities were more likely to be included in fewer calculations for medication adherence measures. For example, among individuals with all 3 conditions, the adjusted relative risk ratios for Black, compared to White, beneficiaries for being included in 0, 1, and 2 measures, versus all 3 measures, were 2.14 (95% CI = 1.99-2.30), 1.49 (95% CI = 1.41-1.56), 1.20 (95% CI = 1.18-1.23), respectively.

CONCLUSIONS

Compared to White beneficiaries, racial/ethnic minorities are more likely to be excluded from the calculation for adherence measures among individuals with diabetes, hypertension, and/or hyperlipidemia. Future studies should examine whether such disparities exacerbate existing racial/ethnic disparities in health outcomes and devise solutions for these disparities.

Trends in Older Adults' Knowledge of Medicare Advantage Benefits, 2010 to 2016

BACKGROUND/OBJECTIVES

The Medicare Advantage (MA) program insures a rapidly growing proportion of older adults, and may be more appealing due to lower cost sharing. However, the extent to which older adults are informed of their plan benefits and how plan knowledge has changed over time is unclear. We evaluated temporal trends and characteristics associated with not knowing MA coverage for dental, vision, and nursing home (NH) services.

DESIGN

Longitudinal cohort study.

SETTING

Medicare Current Beneficiary Survey (MCBS), 2010 to 2016.

PARTICIPANTS

Adults aged 65 years or older enrolled in MA plans and not in Medicaid.

MEASUREMENTS

Insurance knowledge was determined from separate items asking if individuals had coverage through their MA plan for dental, vision, and NH care. Responses were dichotomized between responding yes/no and not knowing. Demographic, clinical, and functional characteristics were assessed from the MCBS.

RESULTS

The proportion of older adults in MA who did not know if their plan covered NH care increased from 38.0% in 2010 to 45.5% in 2016. However, proportions of not knowing dental benefits decreased from 6.4% in 2010 to 3.4% in 2016 and not knowing vision benefits decreased from 8.2% in 2010 to 5.9% in 2016. We found significant associations of race, education, income, region, and disability with knowledge of MA benefits.

CONCLUSIONS

As enrollment in MA plans has grown, older adults in MA plans increasingly report that they know their plan's vision and dental benefits, although they decreasingly know about NH care. Older adults from racial and ethnic minority groups, with lower levels of education and income and who reside in certain regions or have functional disability, are less likely to know their plan benefits. This may imply decreasing preparedness for future long-term care needs. J Am Geriatr Soc 68:2343-2347, 2020.

Plan Switching and Stickiness in Medicare Advantage: A Qualitative Interview With Medicare Advantage Beneficiaries

Approximately 34% of all Medicare beneficiaries were enrolled in a Medicare Advantage (MA) plan in 2019. Quantitative evidence suggests that MA beneficiaries have low rates of switching plans, but that beneficiaries who are hospitalized or use postacute nursing home care are disproportionately more likely to exit their plan. This research sought to explore how MA enrollees choose plans and the factors involved in their decision to keep their current plan or switch plans. We conducted 25 semistructured interviews focusing on expectations and experiences preenrollment and postenrollment among MA beneficiaries. Overall, the beneficiaries interviewed reported being highly satisfied with their plans. After selecting a plan, there was little incentive to revisit their choice since they viewed their plan as "good enough." Confusion, health status, cost and benefits also contributed to many seniors keeping or switching their plans. These seniors were reluctant to switch plans unless they experienced a major health event.

Switching Costs in Medicare Advantage

This paper estimates the magnitude of switching costs in the Medicare Advantage program. Consumers are generally assumed to pick plans that provide the combination of benefits and premiums that maximize their individual utility. However, the plan choice literature has generally omitted prior choices from choice models. The analysis is based on five years of the Medicare Current Beneficiary Survey, a nationally representative longitudinal dataset. The MCBS data were combined with data on Medicare Advantage Part C plan benefits and premiums. Individual choices are modeled as a function of individual characteristics, plan characteristics and prior year plan choices using a mixed logit model. We found relatively high rates of switching between plans within insurer (20%), although less switching between insurers. Prior year plan choices were highly significant at both the contract and plan level. Premium was negative and significant. Loyalty (contract and plan), premium and plan structure were found to be heterogeneous in preferences. We found a statistically significant willingness to pay for a lower prescription drug deductible and lower copays. Switching costs were higher for sicker individuals. Switching costs between plans offered by the same insurer are far lower than switching costs between insurers; beneficiaries will switch plans if an alternative is perceived as $233 a month better than the current choice and switch insurers if the alternative is perceived as $944 better than the current plan/contract, on average. Premium elasticities would be 34% greater in magnitude if prior choices were irrelevant. We provide evidence that the state dependence is structural rather than spurious.

Impact of Star Rating Medication Adherence Measures on Adherence for Targeted and Nontargeted Medications

BACKGROUND

In 2012, Medicare incorporated medication adherence targeting oral antidiabetic medications, renin-angiotensin system (RAS) antagonists, and statins as highly weighted components in its Star Ratings Program. In the same year, health plans began receiving quality bonus payments for higher star ratings.

OBJECTIVE

We aimed to assess how these policy changes affected adherence to targeted and other chronic disease medications in the United States.

METHODS

We performed interrupted time series analyses to assess monthly changes in medication adherence from 2010 to 2016 using health plans' Medicare claims submitted to a large pharmacy benefits manager. We conducted 2 sets of analyses. The first examined whether policy changes affected adherence to the 3 targeted therapy classes, and the second assessed the association between policy changes and adherence to 5 chronic disease classes not targeted by star ratings. For the second analysis, we further compared adherence between members who concomitantly used and did not use targeted medications.

RESULTS

For star-ratings analyses, we studied 240 811 members on oral antidiabetic medications, 500 958 on RAS antagonists, and 471 135 on statins. Adherence for all star rating-targeted and nontargeted medications increased after 2012 (P < .001). Oral antidiabetic, statin, and RAS antagonist adherence was, respectively, 11.2%, 3.7%, and 8.1% higher than adherence without policy changes (P < .001). Nontargeted antihypertensive and antihyperlipidemic adherence trends were higher among those concomitantly on star rating-targeted medications compared with those who were not (P < .001).

CONCLUSIONS

As policy makers strive to identify optimal quality measures for improving healthcare delivery, it is important to consider that incentives can promote improved performance in both targeted measures and related outcomes.

Hematopoietic PBX-interacting protein is a substrate and an inhibitor of the APC/C-Cdc20 complex and regulates mitosis by stabilizing cyclin B1

Proper cell division relies on the coordinated regulation between a structural component, the mitotic spindle, and a regulatory component, anaphase-promoting complex/cyclosome (APC/C). Hematopoietic PBX-interacting protein (HPIP) is a microtubule-associated protein that plays a pivotal role in cell proliferation, cell migration, and tumor metastasis. Here, using HEK293T and HeLa cells, along with immunoprecipitation and immunoblotting, live-cell imaging, and protein-stability assays, we report that HPIP expression oscillates throughout the cell cycle and that its depletion delays cell division. We noted that by utilizing its D box and IR domain, HPIP plays a dual role both as a substrate and inhibitor, respectively, of the APC/C complex. We observed that HPIP enhances the G₂/M transition of the cell cycle by transiently stabilizing cyclin B1 by preventing APC/C-Cdc20-mediated degradation, thereby ensuring timely mitotic entry. We also uncovered that HPIP associates with the mitotic spindle and that its depletion leads to the formation of multiple mitotic spindles and chromosomal abnormalities, results in defects in cytokinesis, and delays mitotic exit. Our findings uncover HPIP as both a substrate and an inhibitor of APC/C-Cdc20 that maintains the temporal stability of cyclin B1 during the G₂/M transition and thereby controls mitosis and cell division.

Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries

IMPORTANCE

How often enrollees with complex care needs leave the Medicare Advantage (MA) program and what might drive their decisions remain unknown.

OBJECTIVE

To characterize trends in switching to and from MA among high-need beneficiaries and to evaluate the drivers of disenrollment decisions.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of MA and traditional Medicare (TM) enrollees from January 1, 2014, through December 31, 2015, used a multinomial logit regression stratified by Medicare-Medicaid eligibility status. All 14 589 645 non-high-need MA enrollees and 1 302 470 high-need enrollees in the United States who survived until the end of 2014 were eligible for the analysis. Data were analyzed from November 1, 2017, through August 1, 2018.

EXPOSURES

Enrollee dual eligibility and high-need status (based on complex chronic conditions, multiple morbidities, use of health care services, functional impairment, and frailty indicators), MA plan star rating, and cost sharing.

MAIN OUTCOMES AND MEASURES

The proportion of enrollees who disenrolled into TM, remained in the same MA plan, or who switched plans within the MA program.

RESULTS

A total of 13 901 816 enrollees were included in the analysis (56.2% women; mean [SD] age, 70.9 [9.9] years). Among the 1 302 470 high-need enrollees, an adjusted 4.6% (95% CI, 4.5%-4.6%) of Medicare-only and 14.8% (95% CI, 14.5%-15.0%) of Medicare-Medicaid members switched from MA to TM compared with 3.3% (95% CI, 3.3%-3.3%) and 4.6% (95% CI, 4.5%-4.7%), respectively, among non-high-need enrollees. Among enrollees in low-quality plans, 23.0% (95% CI, 22.3%-23.9%) of Medicare and 42.8% (95% CI, 40.5%-45.1%) of dual-eligible high-need enrollees left MA. Even in high-quality plans, high-need members disenrolled at higher rates than non-high-need members (4.9% [95% CI, 4.6%-5.2%] vs 1.8% [95% CI, 1.8%-1.9%] for Medicare-only enrollees and 11.3% vs 2.4% dual eligible enrollees). Enrollment in a 5.0-star rated plan was associated with a 30.1-percentage point reduction (95% CI, -31.7 to -28.4 percentage points) in the probability of disenrollment among high-need individuals. A $100 increase in monthly premiums was associated with a 33.9-percentage point increase (95% CI, -34.9 to -33.0 percentage points) in the likelihood of switching plans, and a small reduction in the likelihood of disenrolling (-2.7 percentage points; 95% CI, -3.2 to -2.2 percentage points). Among Medicare-Medicaid eligible participants, 14.1% (95% CI, 14.0%-14.2%) of high-need and 16.7% (95% CI, 16.6%-16.7%) of non-high-need enrollees switched from TM to MA.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that substantially higher disenrollment from MA plans occurs among high-need and Medicare-Medicaid eligible enrollees. This study's findings suggest that star ratings have the strongest association with disenrollment trends, whereas increases in monthly premiums are associated with greater likelihood of switching plans.

Real-world adherence for direct oral anticoagulants in a newly diagnosed atrial fibrillation cohort: does the dosing interval matter?

Background

Differences in adherence may represent drug properties (e.g. dosing interval) or patient experiences while on treatment. Adherence to direct oral anticoagulants (DOACs) in nonvalvular atrial fibrillation (NVAF) is important to maintain effectiveness over the course of treatment.

Methods

This was a retrospective cohort study using 2009–2015 Truven Health MarketScan Databases. New initiators of dabigatran, rivaroxaban, and apixaban with NVAF were identified. Twelve months of continuous enrollment before treatment was required to assess demographics and medical history. Proportion of days cover (PDC) was used to measure adherence at 3, 6, 9 and 12-month. Gaps in therapy and treatment switches were also evaluated. Logistic regression was used to compare high adherence (PDC ≥0.80).

Results

A total of 14,864 dabigatran, 16,005 rivaroxaban, and 8078 apixaban users were identified. Apixaban users had the highest adherence overall, with mean PDC at 3, 6, 9, and 12-months of 0.83, 0.76, 0.72, and 0.69, while dabigatran had the lowest adherence of 0.78, 0.67, 0.61, and 0.57. Adherence to DOACs increased with increased stroke risk scores. Adherence was also higher when first days supplied was > 30 days compared to 30 days and when filled via mail order pharmacies. Switching was highest among dabigatran users. Apixaban users were the most likely to have high adherence versus dabigatran (OR = 1.73, 95% CI = 1.60–1.88) and versus rivaroxaban (OR = 1.24, 95% CI = 1.14–1.34) at 12-months.

Conclusions

Apixaban users had the highest overall adherence despite twice-daily dosing versus once-daily dosing for rivaroxaban. These findings can be useful for formulary decision-making and when assessing treatment options.

Association between Higher Generic Drug Use and Medicare Part D Star Ratings: An Observational Analysis

BACKGROUND

Increasing generic drug use, due to potential for cost savings and drug access, is a viable consideration for Medicare prescription drug plans to achieve high star ratings and improve quality of plan offerings for Medicare beneficiaries.

OBJECTIVE

To examine the association between contract-level proportion of generic drugs dispensed (pGDD) and Medicare Part D star ratings.

METHODS

This was a retrospective study of linked 2011 Medicare Part D star rating data with contract-level pGDD data. A total of 477 individual Medicare prescription contracts were included, representing 75% of total Prescription Drug Plans and more than 65% of total Medicare Advantage Prescription Drug Plans available by the end of 2010. Primary outcomes were Medicare Part D summary and domain star ratings (1-5 indicating lowest to highest performance), incorporating a range of quality measures for access, cost, beneficiary satisfaction, and health services outcomes and processes. Ordinal logistic regression models were used to examine associations between pGDD and Medicare Part D summary and domain star ratings, controlling for contract type and number of beneficiary enrollment.

RESULTS

Higher pGDD was associated with higher summary star ratings (adjusted odds ratio 1.08 with 95% confidence interval 1.04-1.12) and higher "member experience with drug plan" domain ratings (adjusted odds ratio 1.07 with 95% confidence interval 1.03-1.11).

CONCLUSIONS

Prescription formulary benefit design targeting increasing generic drug use appears to be associated with improved member experience and higher plan star ratings. Consideration may be given to incorporating pGDD into Medicare Part D star rating measures to improve quality of prescription plans.

Shifting From Passive Quality Reporting to Active Nudging to Influence Consumer Choice of Health Plan

Comparative quality information on health plan and provider performance is increasingly available in the form of quality report cards, but consumers rarely make use of these passively provided decision support tools. In 2012-2013, the Centers for Medicare & Medicaid Services (CMS) initiated quality-based nudges designed to encourage beneficiaries to move into higher quality Medicare Advantage (MA) plans. We assess the impacts of CMS' targeted quality-based nudges with longitudinal analysis of 2009-2014 MA plan enrollment trends. Nudges are associated with 17% reductions in enrollment in the lowest-performing plans and 3% increases in enrollment in the highest performing plans (annually, p < .01 for both), occurring at the time of nudge implementation and relative to trends for plans with moderate performance that were not targeted by nudges. These findings suggest that quality-based nudges can successfully steer consumers into higher quality plans and provide opportunities for purchasers and payers to increase consumers' use of quality information.

Quality disclosure and the timing of insurers' adjustments: Evidence from medicare advantage

Mandatory quality disclosure often includes a period over which the quality of new entrants is unreported. This provides the opportunity for forward-looking firms to adjust product characteristics in advance of disclosure. Using comprehensive data on Medicare Advantage (MA) from 2007 to 2015, I exploit the design of the MA Star Rating program to examine the presence of forward-looking behavior among insurers. I find that high-quality insurers reduce prices leading up to quality disclosure, while low-quality insurers increase prices in advance of quality disclosure. These dynamics are consistent with firms anticipating a future change in consumer inertia and updating current-period prices accordingly.

Racial and Ethnic Disparities in Meeting MTM Eligibility Criteria Based on Star Ratings Compared with the Medicare Modernization Act

BACKGROUND

Previous research found racial and ethnic disparities in meeting medication therapy management (MTM) eligibility criteria implemented by the Centers for Medicare & Medicaid Services (CMS) in accordance with the Medicare Modernization Act (MMA).

OBJECTIVE

To examine whether alternative MTM eligibility criteria based on the CMS Part D star ratings quality evaluation system can reduce racial and ethnic disparities.

METHODS

This study analyzed the Beneficiary Summary File and claims files for Medicare beneficiaries linked to the Area Health Resource File. Three million Medicare beneficiaries with continuous Parts A, B, and D enrollment in 2012-2013 were included. Proposed star ratings criteria included 9 existing medication safety and adherence measures developed mostly by the Pharmacy Quality Alliance. Logistic regression and the Blinder-Oaxaca approach were used to test disparities in meeting MMA and star ratings eligibility criteria across racial and ethnic groups. Multinomial logistic regression was used to examine whether there was a disparity reduction by comparing individuals who were MTM-eligible under MMA but not under star ratings criteria and those who were MTM-eligible under star ratings criteria but not under the MMA. Concerning MMA-based MTM criteria, main and sensitivity analyses were performed to represent the entire range of the MMA eligibility thresholds reported by plans in 2009, 2013, and proposed by CMS in 2015. Regarding star ratings criteria, meeting any 1 of the 9 measures was examined as the main analysis, and various measure combinations were examined as the sensitivity analyses.

RESULTS

In the main analysis, adjusted odds ratios for non-Hispanic blacks (backs) and Hispanics to non-Hispanic whites (whites) were 1.394 (95% CI = 1.375-1.414) and 1.197 (95% CI = 1.176-1.218), respectively, under star ratings. Blacks were 39.4% and Hispanics were 19.7% more likely to be MTM-eligible than whites. Blacks and Hispanics were less likely to be MTM-eligible than whites in some sensitivity analyses. Disparities were not completely explained by differences in patient characteristics based on the Blinder-Oaxaca approach. The multinomial logistic regression of each main analysis found significant adjusted relative risk ratios (RRR) between whites and blacks for 2009 (RRR = 0.459, 95% CI = 0.438-0.481); 2013 (RRR = 0.449, 95% CI = 0.434-0.465); and 2015 (RRR = 0.436, 95% CI = 0.425-0.446) and between whites and Hispanics for 2009 (RRR = 0.559, 95% CI = 0.528-0.593); 2013 (RRR = 0.544, 95% CI = 0.521-0.569); and 2015 (RRR = 0.503, 95% CI = 0.488-0.518). These findings indicate a significant reduction in racial and ethnic disparities when using star ratings eligibility criteria; for example, black-white disparities in the likelihood of meeting MTM eligibility criteria were reduced by 55.1% based on star ratings compared with MMA in 2013. Similar patterns were found in most sensitivity and disease-specific analyses.

CONCLUSIONS

This study found that minorities were more likely than whites to be MTM-eligible under the star ratings criteria. In addition, MTM eligibility criteria based on star ratings would reduce racial and ethnic disparities associated with MMA in the general Medicare population and those with specific chronic conditions.

DISCLOSURES

Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under award number R01AG049696. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Cushman reports an Eli Lilly grant and uncompensated consulting for Takeda Pharmaceuticals outside this work. The other authors have no potential conflicts of interest to report. Study concept and design were contributed by Wang and Shih, along with Wan, Kuhle, Spivey, and Cushman. Wang, Qiao, and Wan took the lead in data collection, with assistance from the other authors. Data interpretation was performed by Wang, Kuhle, and Qiao, with assistance from the other authors. The manuscript was written by Spivey and Qiao, along with the other authors, and revised by Cushman, Dagogo-Jack, and Chisholm-Burns, along with the other authors.

Preferred Provider Relationships Between Medicare Advantage Plans and Skilled Nursing Facilities Reduce Switching Out of Plans: An Observational Analysis

Unlike traditional Medicare, Medicare Advantage (MA) plans contract with specific skilled nursing facilities (SNFs). Patients treated in an MA plan's preferred SNF may benefit from enhanced coordination and have a lower likelihood of switching out of their plan. Using 2011-2014 Medicare enrollment data, the Medicare Healthcare Effectiveness Data and Information Set, and the Minimum Data Set, we examined Medicare enrollees who were newly admitted to SNFs in 2012-2013. We used the Centers for Medicare & Medicaid Services star rating to distinguish between MA plans and show how SNF concentration experienced by patients varies between patients in plans with different star ratings. We found that highly rated MA plans steer their patients to a smaller number of SNFs, and these patients are less likely to switch out of their plans. Strengthening the MA plan-SNF relationship may lower disenrollment rates for SNF beneficiaries, imparting benefits to both patients and payers.

Medicare Advantage Ratings And Voluntary Disenrollment Among Patients With End-Stage Renal Disease

Populations with intensive health care needs and high care costs may be attracted to insurance plans that have high quality ratings, but patients may be likely to disenroll from a plan if their care needs are not met. We assessed the association between publicly reported Medicare Advantage plan star ratings and voluntary disenrollment of incident dialysis patients in the following year over the period 2007-13. We found that Medicare Advantage (MA) plans with lower star ratings had significantly higher rates of disenrollment by incident dialysis patients in the following year. Compared to MA plans with 4.0 or more stars, adjusted disenrollment rates were 3.9 percentage points higher for plans with 3.5 stars, 5.0 percentage points higher for those with 3.0 stars, and 12.1 percentage points higher for those with 2.5 or fewer stars. These findings suggest that low plan quality may lead to increased expenditures, as this high-cost population generally must shift from Medicare Advantage to traditional Medicare upon disenrollment.

Insurers' response to selection risk: Evidence from Medicare enrollment reforms

Evidence on insurers' behavior in environments with both risk selection and market power is largely missing. We fill this gap by providing one of the first empirical accounts of how insurers adjust plan features when faced with potential changes in selection. Our strategy exploits a 2012 reform allowing Medicare enrollees to switch to 5-star contracts at anytime. This policy increased enrollment into 5-star contracts, but without risk selection worsening. Our findings show that this is due to 5-star plans lowering both premiums and generosity, thus becoming more appealing for most beneficiaries, but less so for those in worse health conditions.

Adherence to Rivaroxaban, Dabigatran, and Apixaban for Stroke Prevention for Newly Diagnosed and Treatment-Naive Atrial Fibrillation Patients: An Update Using 2013-2014 Data

BACKGROUND

Few studies have assessed adherence to non-vitamin K antagonist oral anticoagulants (NOACs), especially using contemporary data now that multiple NOACs are available.

OBJECTIVE

To compare adherence and treatment patterns among NOACs for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF).

METHODS

Incident and treatment-naive NVAF patients were identified during 2013-2014 from a large claims database in this retrospective cohort study. Patients were included who initiated rivaroxaban, dabigatran, or apixaban within 30 days after diagnosis. Adherence to the index medication and adherence to any oral anticoagulant was assessed using the proportion of days covered (PDC) at 3, 6, and 9 months. The number of switches and gaps in therapy were also evaluated. Analyses were stratified by stroke risk scores, and a logistic regression model was used to control for factors that may predict high adherence.

RESULTS

Dabigatran had lower adherence (PDC = 0.76, 0.64, 0.57) compared with rivaroxaban (PDC = 0.83, 0.73, 0.66; P < 0.001) and apixaban (PDC = 0.82, 0.72, 0.66; P < 0.001) at 3, 6, and 9 months of follow-up and twice the number of switches to either other anticoagulants or antiplatelet therapy. Adherence was higher overall as stroke risk increased, and dabigatran had consistently lower adherence compared with the other NOACs. Multivariable logistic regression predicting PDC ≥ 0.80 showed rivaroxaban users with higher odds of high adherence compared with dabigatran or rivaroxaban across all time periods. Adjusted analyses showed that increasing age and comorbid hypertension and diabetes were associated with higher adherence.

CONCLUSIONS

In this real-world analysis of adherence to NOACs, rivaroxaban and apixaban had favorable unadjusted adherence profiles compared with dabigatran, while rivaroxaban users had higher odds of high adherence (PDC ≥ 0.80) among the NOACs in adjusted analyses. Clinicians and managed care organizations should consider the implications of lower adherence on clinical outcomes and quality assessment.

DISCLOSURES

This project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1TR000117. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors have nothing to disclose. Study concept and design were contributed by Brown and Shewale. Brown and Talbert collected the data, and data analysis was performed primarily by Brown, along with Shewale and Talbert. The manuscript was written primarily by Brown, along with Shewale, and revised by all the authors.

Medicare Advantage Associated With More Racial Disparity Than Traditional Medicare For Hospital Readmissions

We compared racial disparities in thirty-day readmissions between traditional Medicare and Medicare Advantage beneficiaries who underwent one of six major surgeries in New York State in 2013. We found that Medicare Advantage was associated with greater racial disparity, compared to traditional Medicare. After controlling for patient, hospital, and geographic characteristics in a propensity score based approach, we found that in traditional Medicare, black patients were 33 percent more likely than white patients to be readmitted, whereas in Medicare Advantage, black patients were 64 percent more likely than white patients to be readmitted. Our findings suggest that the risk-reduction strategies adopted by Medicare Advantage plans have not been successful in lowering the markedly higher rate of readmission among black patients, compared to white patients.

Understanding the dissemination of appointment-based synchronization models using the CFIR framework

BACKGROUND

The appointment based model (ABM) is a innovative model of pharmacy practice that combines medication synchronization with scheduled monthly appointments to improve patient medication adherence and convenience. It is being implemented in many pharmacies across the United States.

OBJECTIVE

The purpose of this article is to use the Consolidated Framework for Implementation Research (CFIR) to discuss the barriers and facilitators of ABM implementation in community pharmacies while identifying priorities for additional implementation research.

METHODS

A review of current evidence of ABM was examined using the five domains within the CFIR taxonomy. Interactions between these domains (the intervention, the individuals involved, the process used to implement the intervention, the inner setting, and the outer setting) and their sub domains were used to explain the current success of ABM and future barriers.

RESULTS

The CFIR is an effective theoretical framework for assessing ABM. It helps identify key constructs in ABM implementation and their relationships. It also suggests future research to facilitate its adoption as a standard of pharmacy practice.

CONCLUSIONS

The adoption of ABM by pharmacies will be facilitated by better evidence of its clinical and economic impact on patient health outcomes, standardization of ABM, and integrating it into current workflows.

Encouraging Medicare Advantage Enrollees to Switch to Higher Quality Plans: Assessing the Effectiveness of a "Nudge" Letter

There are considerable quality differences across private Medicare Advantage insurance plans, so it is important that beneficiaries make informed choices. During open enrollment for the 2013 coverage year, the Centers for Medicare & Medicaid Services sent letters to beneficiaries enrolled in low-quality Medicare Advantage plans (i.e., plans rated less than 3 stars for at least 3 consecutive years by Medicare) explaining the stars and encouraging them to reexamine their choices. To understand the effectiveness of these low-cost, behavioral “nudge” letters, we used a beneficiary-level national retrospective cohort and performed multivariate regression analysis of plan selection during the 2013 open enrollment period among those enrolled in plans rated less than 3 stars. Our analysis controls for beneficiary demographic characteristics, health and health care spending risks, the availability of alternative higher rated plan options in their local market, and historical disenrollment rates from the plans. We compared the behaviors of those beneficiaries who received the nudge letters with those who enrolled in similar poorly rated plans but did not receive such letters. We found that beneficiaries who received the nudge letter were almost twice as likely (28.0% [95% confidence interval = 27.7%, 28.2%] vs. 15.3% [95% confidence interval = 15.1%, 15.5%]) to switch to a higher rated plan compared with those who did not receive the letter. White beneficiaries, healthier beneficiaries, and those residing in areas with more high-performing plan choices were more likely to switch plans in response to the nudge. Our findings highlight both the importance and efficacy of providing timely and actionable information to beneficiaries about quality in the insurance marketplace to facilitate informed and value-based coverage decisions.

Adherence to Rivaroxaban, Dabigatran, and Apixaban for Stroke Prevention in Incident, Treatment-Naïve Nonvalvular Atrial Fibrillation

BACKGROUND

Non-vitamin K antagonist oral anticoagulants (NOACs) are widely used for prevention of stroke secondary to nonvalvular atrial fibrillation (NVAF). Increased use of NOACs is partially a result of simplified regimens compared with warfarin, which has been associated with poor adherence and persistence to therapy. Few studies have assessed adherence to NOACs, especially using contemporary data now that multiple NOACs are available.

OBJECTIVE

To evaluate adherence to NOACs in a cohort of newly diagnosed NVAF patients who are commercially insured.

METHODS

Incident, treatment-naïve NVAF patients were identified in 2013 from a large claims database. Patients were included who initiated rivaroxaban, dabigatran, or apixaban within 30 days after diagnosis. Subjects were required to have 12 months of pre-index information to assess demographic and clinical characteristics (comorbidities, CHA₂ DS₂-VASc, and HAS-BLED scores). Adherence to the index medication and adherence to any oral anticoagulant was assessed using proportion of days covered (PDC) at 3, 6, and 9 months. The number of switches and gaps in therapy were also evaluated. Analyses were stratified by stroke risk scores, and a logistic regression model was used to control for factors that may predict high adherence (PDC ≥ 0.80).

RESULTS

A total of 3,455 rivaroxaban, 1,264 dabigatran, and 504 apixaban users were included with no major clinical or demographic differences between groups. At 3, 6, and 9 months of follow-up, dabigatran had lower adherence (PDC = 0.77, 0.67, and 0.62) compared with rivaroxaban (PDC = 0.84, 0.75, and 0.70; P < 0.001) and apixaban (PDC = 0.82, 0.75, and 0.71; P < 0.001), as well as nearly twice the number of switches to either other anticoagulants or antiplatelet therapy. At 9 months, 55.0% of rivaroxaban initiators had PDC ≥ 0.80, which was comparable with 56.8% for apixaban and significantly greater than 46.7% for dabigatran (P < 0.001). Adherence was higher overall as stroke risk increased and showed dabigatran had consistently lower adherence compared with the other NOACs. Overall adherence to any oral anticoagulants, allowing for switches to another NOAC or warfarin, was not dependent on the index medication (9-month PDC = 0.74, 0.71, and 0.74 for rivaroxaban, dabigatran, and apixaban initiators). Adjusted analyses showed that increasing age and comorbid hypertension and diabetes were associated with higher adherence. Compared with rivaroxaban, dabigatran initiators had nearly 30% lower odds of being adherent to their index medication, and no differences were observed between apixaban and rivaroxaban. At 9 months, there were no differences between NOACs for overall adherence to oral anticoagulants.

CONCLUSIONS

In this real-world analysis of adherence to NOACs, rivaroxaban and apixaban had favorable profiles compared with dabigatran, and rivaroxaban appeared to have higher overall adherence among the NOACs. Clinicians and managed care organizations should consider the implications of lower adherence on clinical outcomes as well as quality assessment.

DISCLOSURES

The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1TR000117. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Brown reports receiving a training fellowship from Human and Pfizer. Study concept and design were contributed by Brown and Shewale. Talbert took the lead in data collection, along with Brown, and data interpretation was primarily performed by Brown, along with Shewale. The manuscript was written primarily by Brown, along with Shewale, and revised by all the authors.

Is There a Relationship Between Part D Medication Adherence and Part C Intermediate Outcomes Star Ratings Measures?

BACKGROUND

Improvements in the Centers for Medicare & Medicaid Services (CMS) star ratings Part D medication adherence measures may affect performance in Part C intermediate outcome measures for which the Part D targeted medication classes are prescribed.

OBJECTIVE

To determine if Part D medication adherence measures are associated with corresponding Part C intermediate outcome measures.

METHODS

This was a cross-sectional analysis using the CMS 2015 star ratings report (based on 2013 benefit year plan data) for Medicare contracts. The measures of interest included the Part D adherence measures for diabetes medications, antihypertensive agents, and statins and the Part C intermediate outcome measures for controlled blood sugar, blood pressure, and cholesterol. All Medicare Advantage Prescription Drug (MAPD) contracts with complete data for all Part C and D measures of interest were included. Contracts with ≥ 25% of total enrollment with MA-only benefit were excluded. Linear and logistic regression models were used to assess the association between 2015 Part D adherence measures and Part C intermediate outcome measures (n = 366). The regression models were adjusted for low-income subsidy (LIS) beneficiary enrollment and log-transformed (natural logarithm) total contract enrollment.

RESULTS

Bivariate linear regression models demonstrated moderate positive associations between each of the 2015 Part D adherence scores and related 2015 Part C measures that explained 27%-29% (R(2)) of variance. Including LIS and total contract enrollment in the regression models increased the R2 to 30%-36%. The multivariate logistic regression models showed that each percentage point of improvement in the 2015 Part D adherence measures was associated with a 4.13 to 4.69 greater odds of performing in the top quartile in corresponding 2015 Part C measures.

CONCLUSIONS

Moderate positive associations were observed between the Part D and Part C scores in the same benefit year. MAPD plans may observe improved Part C intermediate outcome measures with strategies that improve Part D medication adherence measures.

DISCLOSURES

This study was conducted by MedImpact Healthcare Systems, San Diego, California, without external funding. All authors are employees of MedImpact Healthcare Systems. Erickson reports advisory board fees from Sanofi and AstraZeneca. Ta, Erickson, and Patel were responsible for study concept and design and data interpretation, with assistance from Qiu. Qiu and Ta took the lead in data collection, assisted by Erickson. Ta wrote the manuscript, which was revised by Erickson and Patel.

Medication Nonadherence Among Medicare Beneficiaries with Comorbid Chronic Conditions: Influence of Pharmacy Dispensing Channel

BACKGROUND

Taking medications as prescribed is imperative for their effectiveness. In populations such as Medicare, where two thirds of Medicare beneficiaries have at least 2 or more chronic conditions requiring treatment with medications and account for more than 90% of Medicare health care spend, examining ways to improve medication adherence in patients with comorbidities is warranted.

OBJECTIVE

To examine the association of pharmacy dispensing channel (home delivery or retail pharmacy) with medication adherence for Medicare patients taking medications with comorbid conditions of diabetes, hypertension, and high blood cholesterol (3 of the top 5 most prevalent conditions), while controlling for various confounders.

METHODS

A retrospective analysis was conducted using de-identified pharmacy claims data from a large national pharmacy benefits manager between October 2010 and December 2012. Continuously eligible Medicare Part D patients (Medicare Advantage Prescription Drug plan and Prescription Drug Plan only) aged 65 years or older who had an antidiabetic, antihypertensive, and antihyperlipidemic prescription claim between October and December 2010 were identified and analyzed over a 2-year period. Multivariate logistic regression was used to evaluate the association between dispensing channel (DC) and medication adherence in calendar year (CY) 2012 controlling for prior adherence behavior (adherence in CY2011), differences in demographics, low-income subsidy status, days supply, disease burden, and drug-use pattern. Patients with a proportion of days covered (PDC) of at least 80% for each of the 3 conditions were considered to be adherent, and patients with PDC less than 80% for each of the 3 conditions were considered to be nonadherent. Patients were assigned to a DC depending on where they filled at least 66.7% of their prescriptions for each of the 3 conditions, and the rest were assigned to a mixed channel group.

RESULTS

The final analytical sample consisted of 40,632 patients. The adjusted odds of adherence for patients using home delivery were 1.59 (95% CI = 1.40-1.80) higher compared with patients using retail channels to obtain their prescriptions.

CONCLUSIONS

Medicare Part D patients taking medications for comorbid conditions who used home delivery had a greater likelihood (adjusted) of adherence than patients who filled their antidiabetic, antihypertensive, and antihyperlipidemic prescriptions using retail channels. Managed care stakeholders looking to make informed decisions in a cost-constrained environment to assess, implement, and promote solutions that improve health outcomes should consider the use of home delivery of prescriptions to improve adherence for Medicare Part D patients with comorbid conditions.

DISCLOSURES

Funding for this study was provided internally by Express Scripts Holding Company. Iyengar, LeFrancois, Henderson, and Rabbitt are employees of Express Scripts. Study concept and design were created by Iyengar and LeFrancois. Iyengar was responsible for acquisition of data, statistical analysis, and interpretation of data. The manuscript was written by Iyengar and LeFrancois and revised by all the authors.

Empirical Assessment of the Impact of Low-Cost Generic Programs on Adherence-Based Quality Measures

In the United States, federally-funded health plans are mandated to measure the quality of care. Adherence-based medication quality metrics depend on completeness of administrative claims data for accurate measurement. Low-cost generic programs (LCGPs) cause medications fills to be missing from claims data as medications are not adjudicated through a patient’s insurance. This study sought to assess the magnitude of the impact of LCGPs on these quality measures. Data from the 2012–2013 Medical Expenditure Panel Survey (MEPS) were used. Medication fills for select medication classes were classified as LCGP fills and individuals were classified as never, sometimes, and always users of LCGPs. Individuals were classified based on insurance type (private, Medicare, Medicaid, dual-eligible). The proportion of days covered (PDC) was calculated for each medication class and the proportion of users with PDC ≥ 0.80 was reported as an observed metric for what would be calculated based on claims data and a true metric which included missing medication fills due to LCGPs. True measures of adherence were higher than the observed measures. The effect’s magnitude was highest for private insurance and for medication classes utilized more often through LCGPs. Thus, medication-based quality measures may be underestimated due to LCGPs.