Looking Inside The Nation’s Medicine Cabinet: Trends In Outpatient Drug Spending By Medicare Beneficiaries, 1997 And 2001

Psychoactive medication use among older community-dwelling Americans

BACKGROUND

Falls are a common and serious health issue among older Americans. A common fall risk factor is the use of psychoactive medications. There is limited recent information on the national prevalence of psychoactive medication use among older Americans.

OBJECTIVES

To estimate the prevalence of psychoactive medication use among community-dwelling older Americans and compare it with previous estimates from 1996.

METHODS

The data source was the 2013 Cost and Use Data files combining Medicare claims data and survey data from the Medicare Current Beneficiary Survey, an in-person nationally representative survey of Medicare beneficiaries. Participants were included if they were 65 years of age and older, lived in the community, and had a complete year of prescription use data. Medication use was examined for 7 classes of psychoactive medications categorized by the 2015 American Geriatric Society Beers criteria as increasing fall risk. These include opioids, benzodiazepines, selective serotonin reuptake inhibitors, anticonvulsants, nonbenzodiazepine sedative hypnotics, antipsychotics, and tricyclic antidepressants. Data on participant demographic factors were also collected.

RESULTS

Among the 6959 community-dwelling older adults studied, representing 33,268,104 community-dwelling Medicare beneficiaries, 53.3% used at least 1 psychoactive medication linked to falls in 2013. The most frequently used medication classes were opioids (34.9%), benzodiazepines (15.4%), selective serotonin reuptake inhibitors (14.3%), and anticonvulsants (13.3%). These estimates are considerably higher for all classes except tricyclic antidepressants than previous reports from 1996 that used the same data source. Among most psychoactive medication classes observed, women had higher usage than men.

CONCLUSION

More than half of all older Americans used at least 1 psychoactive medication in 2013. Health care providers, including pharmacists, play a vital role in managing older adults' exposure to psychoactive medications. Medication management can optimize health and reduce older adult falls.

Gender Differences in Out-of-Pocket Prescription Drug Expenditures Among the Elderly

Many elderly in the United States face high out-of-pocket prescription drug (OOP-PD) expenditures, with elderly women being disproportionably affected. Using Medicare Current Beneficiary Survey data for 1992 to 2000, the authors examined the gender differences in OOP-PD expenditures and burden among community-dwelling elderly Medicare beneficiaries. Oaxaca-Blinder decomposition techniques were used to evaluate the contribution of observed demographic, socioeconomic, and utilization factors on the gender gap in OOP-PD expenditures and burden. Among observed characteristics, differences in utilization and supplemental insurance coverage were the major drivers of the gender gap in OOP-PD expenditures and burden. Unobservable factors contributed to the majority of the gender gap in OOP-PD expenditures.

Adverse selection and the effect of health insurance on utilization of prescribed medicine among patients with chronic conditions

PURPOSE

To examine the effects of health insurance types on the use of prescribed medication that treat patients with hypertension, diabetes, and asthma. The study distinguishes between individuals with private health maintenance organization (HMO) plans and private non-HMO plans. The study also distinguishes between people with health insurance and drug coverage and people with health insurance and no drug coverage.

METHODS

Joint discrete factor models are estimated to control for endogeneity of each type of coverage.

FINDINGS

The main findings suggest that the effect of health insurance varies across patients with different conditions. The strongest and most significant effect is evident among patients with hypertension while the weakest and least significant is among patients with asthma. These findings suggest that patients with asymptomatic conditions are more likely to exhibit moral hazard than patients with conditions that impose immediate impairment. Additional results suggest that, relative to the uninsured and people with health insurance but no drug coverage, patients with drug coverage are more likely to initiate drug therapy and to consume more medications.

ORIGINALITY

The results of the study indicate that moral hazard of drug utilization is condition specific. The variation in "silence" of conditions' symptoms could be a key reason for difference in insurance effects among patients with hypertension, diabetes, and asthma.

Cost savings associated with filling a 3-month supply of prescription medicines

BACKGROUND

Many patients are burdened by prescription costs, and patients, providers and policy makers may attempt to reduce these costs by substituting 3-month for 1-month supplies of medicines.

OBJECTIVES

To measure the difference in out-of-pocket and total costs among patients receiving different quantities of the same prescription drug used to treat a chronic condition, and to examine patient and health system characteristics associated with the use of a 3-month supply.

METHODS

Data were pooled from the 2000-5 Medical Expenditure Panel Survey, a nationally representative survey of the US non-institutionalized civilian population, to compare prescription drug expenditures for medicines dispensed as both 3-month and 1-month supplies. Logistic regression was used to model correlates associated with 3-month use. The main outcome measures were the mean monthly out-of-pocket and total costs expressed in year 2005 values.

RESULTS

Forty-four percent of prescriptions examined were dispensed as 3-month supplies. The average (95% CI) monthly total and out-of-pocket costs for a 1-month supply were $US42.72 (42.01, 43.42) and $US20.44 (19.99, 20.89), respectively, while the corresponding monthly costs for a 3-month supply were $US37.95 (37.26, 38.64) and $US15.10 (14.68, 15.53). After adjustment for potential confounders, this represented a 29% decrease in out-of-pocket costs and an 18% decrease in total prescription costs through the use of a 3-month rather than a 1-month supply. Eighty percent of patients achieved some cost savings from a 3-month supply and there was considerable variation in the amount saved. There were no marked differences in the characteristics of individuals using 3-month versus 1-month supplies.

CONCLUSIONS

Although such opportunities are not universally available, these findings quantify the cost savings that patients in the US can achieve through filling larger quantities of a prescription for a chronic condition.

Why is late-life disability declining?

CONTEXT

Late-life disability has been declining in the United States since the 1980s. This study provides the first comprehensive investigation into the reasons for this trend.

METHODS

The study draws on evidence from two sources: original data analyses and reviews of existing studies. The original analyses include trend models of data on the need for help with daily activities and self-reported causes of such limitations for the population aged seventy and older, based on the National Health Interview Surveys from 1982 to 2005.

FINDINGS

Increases in the use of assistive and mainstream technologies likely have been important, as have declines in heart and circulatory conditions, vision, and musculoskeletal conditions as reported causes of disability. The timing of the improvements in these conditions corresponds to the expansion in medical procedures and pharmacologic treatment for cardiovascular disease, increases in cataract surgery, increases in knee and joint replacements, and expansion of medications for arthritic and rheumatic conditions. Greater educational attainment, declines in poverty, and declines in widowhood also appear to have contributed. Changes in smoking behavior, the population's racial/ethnic composition, the proportion of foreign born, and several specific conditions were eliminated as probable causes.

CONCLUSIONS

The substantial reductions in old-age disability between the early 1980s and early 2000s are likely due to advances in medical care as well as changes in socioeconomic factors. More research is needed on the influence of health behaviors, the environment, and early- and midlife factors on trends in late-life disability.

Chronic conditions and the decline in late-life disability

Using data from the 1997-2004 National Health Interview Survey (NHIS), we examine the role of chronic conditions in recent declines in late-life disability prevalence. Building upon prior studies, we decompose disability declines into changes in the prevalence of chronic conditions and in the risk of disability given a condition. In doing so, we extend Kitigawa's (1955) classical decomposition technique to take advantage of the annual data points in the NHIS. Then we use respondents' reports of conditions causing their disability to repartition these traditional decomposition components. We find a general pattern of increasing prevalence of chronic conditions accompanied by declines in the percentage reporting disability among those with a given condition. We also find declines in heart and circulatory conditions, vision impairments, and possibly arthritis and increases in obesity as reported causes of disability. Based on decomposition analyses, we conclude that heart and circulatory conditions as well as vision limitations played a major role in recent declines in late-life disability prevalence and that arthritis may also be a contributing factor. We discuss these findings in light of improvements in treatments and changes in the environments of older adults.

Trends and geographic variation of opiate medication use in state Medicaid fee-for-service programs, 1996 to 2002

BACKGROUND

Although studies have documented hospital and surgical service geographic variability, prescription use geographic variability is largely unknown. Opiate pain medications are widely used, particularly because the promulgation of clinical guidelines promoting aggressive pain treatment. This study describes temporal and interstate variability in aggregate prescription opiate medication use within U.S. Medicaid programs.

METHODS

A dataset of 49 states' fee-for-service (FFS) Medicaid prescription drug dispensing records from 1996 to 2002 was compiled and used to quantify medication dispensing examining all opiates, controlled release oxycodone, and methadone. The defined daily dose (DDD) per 1000 FFS Medicaid adult enrollees per day was calculated for all opiate medication categories. A market basket of nonpain prescription medications was constructed for comparison. Rates, trends, and the coefficient of variation were determined overall, by year and for each state.

RESULTS

From 1996 to 2002, overall use of opiate pain medications increased 309%. The market basket use increased 170%. Total opiate dispensing varied widely from state to state, with a range of 6.9 to 44.1 DDD/1000/d in 1996, and 7.1 to 165.0 DDD/1000/d (a 23-fold difference) in 2002. The coefficient of variation was 49.6 in 2002. Controlled release oxycodone and methadone had a greater rate of increase compared with all opiates.

CONCLUSIONS

The dispensing of opiate medications in Medicaid programs increased at almost twice the rate of nonpain-related medications during the 7-year study period. Large, unexplained geographic variation in aggregate use exists. The impact of Medicaid cost-containment strategies on utilization and outcomes should be investigated.

Trends in prescription drug expenditures by Medicaid enrollees

OBJECTIVE

As prescription drug expenditures consume an increasingly larger portion of Medicaid budgets, states are anxious to control drug costs without endangering enrollees' health. In this report, we analyzed recent trends in Medicaid prescription drug expenditures by therapeutic classes and subclasses. Identifying the fastest growing categories of drugs, where drugs are grouped into clinically relevant classes and subclasses, can help policymakers decide where to focus their cost containment efforts.

METHODS

We used data from the Medical Expenditure Panel Survey linked to a prescription drug therapeutic classification system, to examine trends between 1996/1997 and 2001/2002 in utilization and expenditures for the noninstitutionalized Medicaid population. We separated aggregate trends into changes in population with use and changes in expenditures per user, and percent generic. We also highlighted differences within the Medicaid population, including children, adults, disabled, and elderly.

RESULTS

We found rapid growth in expenditures for antidepressants, antipsychotics, antihyperlipidemics, antidiabetic agents, antihistamines, COX-2 inhibitors, and proton pump inhibitors and found evidence supporting the rapid take-up of new drugs. In some cases these increases are the result of increased expenditures per user and in other cases the overall growth also comes from an increase in the population with use.

CONCLUSIONS

Medicaid programs may want to reassess their cost-containment policies in light of the rapid take-up of new drugs. Our analysis also identifies areas in which more information is needed on the comparative effectiveness of new versus existing treatments.

Recent trends in mortality from unintentional injury in the United States

INTRODUCTION

Recent observations suggest that the unintentional injury mortality rate may be increasing in the United States for the first time since 1979.

METHOD

This study examined trends in unintentional injury mortality by sex, race, mechanism, and age group to better understand these increases.

RESULTS

From 1992 to 2002, mortality increased 11.0% (6.5% for males, 18.5% for females). The mortality rate increased 16.5% among whites, but declined among African Americans and other races. Rates among whites exceeded rates among African Americans for the first time since 1998. Fall rates increased 39.5% from 1992 to 2002, and poisoning rates increased 121.5%. Motor-vehicle rates did not increase overall. Rates in age groups from 40-64 years of age increased for falls, poisoning, and motor-vehicle crashes. Only fall rates increased for the 65+ age group.

CONCLUSIONS

These results raise the issue of whether these increases have one or more risk factors in common, such as recent increases in the use of alcohol and prescription drugs.

Principles for evidence-based drug formulary policy

Expenditures for prescription drugs continue to increase, prompting insurers and health systems to adopt formulary or coverage policies restricting the use of more expensive drugs. Those establishing formulary policies face a complex array of claims regarding differences in efficacy, safety, treatment cost, or cost-effectiveness. We describe and illustrate 5 specific principles for applying research evidence to formulary decisions: (1) Experimental data should take precedence over models or simulations, and assumptions of such models should be carefully examined. (2) Morbidity or mortality outcomes should take precedence over surrogate or intermediate outcomes. (3) Claims for advantages of new treatments should consider the full range of alternatives rather than those selected by industry. (4) Variation in effects across individuals or subgroups argue against restrictions on first-line treatment, but only if those differences are predictable. (5) Variation in effects argues against requiring changes in ongoing treatment. We also discuss how economic incentives are likely to influence selection of research questions, especially research related to drug-gene interactions and to identifying new indications for existing drugs.

Gender Differences in Drug Use and Expenditures in a Privately Insured Population of Older Adults

We examine gender differences in use and expenditures for prescription drugs among Medicare and privately insured older adults aged 65 and over, using data on a nationally representative sample of prescription drug purchases collected for the Medical Expenditure Panel Survey Household Component. Overall, women spent about $1,178 for drugs, about 17% more than the $1,009 in average expenditures by men. Older women constituted 50.7% of the population and had average annual aggregate expenditures for prescribed medicines of $6.93 billion compared to $5.77 billion for men. Women were more likely than men to use drugs from a number of therapeutic classes-analgesics, hormones and psychotherapeutic agents-and therapeutic subclasses-thyroid drugs, COX-2 inhibitors and anti-depressants. Women also had higher average prescriptions per user for a number of therapeutic classes-hormones, psychotherapeutic agents and analgesics-and therapeutic subclasses-anti-diabetic drugs and beta blockers. Prescribed medications are, arguably, the most important healthcare technology in preventing illness, disability, and death in older adults. It is critical that older women and men have proper access to prescribed medicines. Given the financial vulnerability of this priority population, particularly women, the expanded drug coverage available under the Medicare Modernization Act is of particular relevance in meeting this goal.