Disparity implications of the Medicare medication therapy management eligibility criteria: a literature review

Effects of star ratings bonus payments on disparities in medication utilization issues

Background

Previous literature suggested that the consequences of inappropriate medication use may be borne disproportionately by racial/ethnic minorities. It is, therefore, essential to examine if quality improvement initiatives, such as Medicare Part D Star Ratings (Star Ratings), can improve these disparities.

Objective

To assess the impact of Star Ratings bonus payments to Medicare Advantage prescription drug plans (MAPDs) implemented in 2012 on racial/ethnic disparities in medication utilization issues (MUIs).

Methods

This study mainly used secondary data from Medicare administrative data linked to Area Health Resources Files for years before (2010-2011) and after MAPD bonus payment implementation (2016-2017). Patients in MAPDs were treated as the intervention group, and those in independent prescription drug plans (PDPs) were used as the comparison group because PDPs were ineligible for bonuses. MUIs targeted and not targeted in Star Ratings were both examined to determine spillover effects. A difference-in-differences approach was applied by including in a logistic regression a 3-way interaction term for dummy variables for racial/ethnic minorities, later period of 2016-2017, and MAPD plan.

Results

Racial/ethnic minorities experienced more MUIs: e.g., the odds of MUIs targeted in Star Ratings among MAPD enrollees were 83% higher (odds ratio [OR] = 1.83; 95% confidence interval [CI] = 1.71-1.96) for Black than White patients. Black-White disparities in MUIs targeted in Star Ratings decreased 16% more (OR = 0.84; 95% = CI 0.78-0.91) over time among MAPD enrollees than those in PDPs. This pattern was not found for non-Star Ratings measures. Changes in Hispanic-White disparities were similar between MAPD and PDP enrollees for MUIs targeted and not-targeted by Star Ratings. Asian-White and Other-White disparities in MUIs did not experience a higher reduction among MAPD enrollees than PDP enrollees.

Conclusions

Part D bonus payments are associated with lower Black-White disparities in MUIs targeted by Star Ratings. However, Part D bonus payments may not have reduced Hispanic-White or Asian-White disparities. Future research should explore the causes of the bonus payments' heterogeneous effects across racial/ethnic groups.

Effects of the Medicare Part D Comprehensive Medication Review on Racial and Ethnic Disparities in Medication Adherence

Background

Substantial research has documented inequalities between US minorities and whites in meeting the eligibility criteria for the Medicare Part D medication therapy management (MTM) program. Even though the Centers for Medicare & Medicaid Services attempted to relax the eligibility criteria, a critical barrier to effective MTM reform is a lack of stronger evidence about the effects of MTM on minorities' health outcomes.

Objective

To examine the effects of comprehensive medication review (CMR), an MTM core component, on racial and ethnic disparities in adherence to diabetes, hypertension, and hyperlipidemia medications among Medicare beneficiaries aged ≥65 years.

Methods

This study used full-year 2017 Medicare Parts A, B, and D claims data, including MTM data, linked to the Area Health Resources Files. Racial and ethnic disparities in nonadherence to diabetes, hypertension, and hyperlipidemia medications were compared between CMR recipients and nonrecipients matched by their propensity scores. To determine the changes in racial and ethnic disparities after receiving CMR, a difference-in-differences framework was applied, by including in logistic regression analyses interaction terms between dummy variables for CMR receipt and each racial or ethnic minority group.

Results

Compared with CMR nonrecipients, CMR recipients had significantly lower racial and ethnic disparities across the 3 outcome measures, with the exception of the difference between whites and blacks in nonadherence to diabetes medications. For example, compared with CMR nonrecipients, among CMR recipients the differences in the odds of nonadherence to hypertension medications were reduced, respectively, by 8% (95% confidence interval [CI], 0.88-0.96) between whites and blacks; by 18% (95% CI, 0.78-0.86) between whites and Hispanics; by 16% (95% CI, 0.77-0.91) between whites and Asians; and by 9% (95% CI, 0.85-0.98) between whites and other racial and ethnic groups.

Conclusion

Receiving a CMR reduced the racial and ethnic disparities in adherence to diabetes, hypertension, and hyperlipidemia medications among Medicare beneficiaries aged ≥65 years. These findings provide critical empirical evidence that may inform the future design of the Medicare Part D MTM program, which is valuable for improving pharmacotherapy outcomes and could further realize its potential when additional people from racial and ethnic minorities are enrolled.

Exploring racial and ethnic disparities in medication adherence among Medicare comprehensive medication review recipients

Background

There has been a lack of evidence on whether there are racial and ethnic disparities in medication nonadherence among individuals receiving comprehensive medication review (CMR), a required component of the Medicare Part D medication therapy management (MTM) services.

Objectives

To explore racial/ethnic disparities in medication nonadherence among older MTM enrollees who received a CMR and to determine how much the identified disparities can be explained by observed characteristics.

Methods

The retrospective study used 100% of the 2017 Medicare claims, including MTM data. Linked Area Health Resources Files provided community characteristics. Nonadherence was defined as proportion of days covered <80%, and was measured for diabetes, hypertension, and hyperlipidemia medications. Racial/ethnic disparities were examined by logistic regressions that included racial/ethnic minority dummy variables. A nonlinear Blinder-Oaxaca decomposition method was applied to decompose the identified disparities.

Results

Compared with non-Hispanic Whites (Whites), Blacks were respectively 39% (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.33–1.45), 27% (OR = 1.27, 95% CI = 1.22–1.32), and 43% (OR = 1.43, 95% CI = 1.39–1.47) more likely to be nonadherent to diabetes, hypertension, and hyperlipidemia medications; Hispanics were 20% (OR = 1.20, 95% CI = 1.14–1.27) more likely to be nonadherent to hyperlipidemia medications. The total portion of disparity explained was 13.42%, 7.66%, 14.87%, and 10.69% respectively for disparities in Black-White (B–W) diabetes, B–W hypertension, B–W hyperlipidemia, and Hispanic-White hyperlipidemia. The top three contributors were the proportion of married-couple families, census region, and male gender.

Conclusions

A lower level of community affluence and social support, regional variations, and a lower proportion of males in Blacks and Hispanics may contribute to the disparities in medication nonadherence. The large unexplained portion of the disparity attests that nonadherence is a complex issue. The Medicare MTM program needs to implement measures to reduce disparities in medication adherence.

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This retrospective study used 100% of the 2017 Medicare claims including MTM data.

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Racial/ethnic disparity in medication adherence was identified among CMR recipients.

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Blacks were more likely than Whites to be nonadherent to all medications studied.

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Hispanics were more likely than Whites to be hyperlipidemia medication nonadherent.

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Observed characteristics explained close to 15% of the identified disparity.

Community health worker perspectives of an academic community medication therapy management collaboration

OBJECTIVE

To qualitatively assess community health workers' (CHWs') perceptions of the challenges and benefits associated with participating in a collaborative, interprofessional medication therapy management (MTM) program for rural, underserved, predominantly Latinx, patients with diabetes and hypertension.

METHODS

Nine CHWs participated in a 1-hour, semistructured focus group that explored their experiences while assisting in the delivery of MTM services through an academic community partnership between an MTM provider and participating rural clinics. Audio recordings of the focus group were transcribed and thematically analyzed by 2 independent reviewers.

RESULTS

All program-involved CHWs participated in the focus group. Qualitative analysis identified 2 overarching themes: (1) opportunities and (2) challenges. Opportunities were further subcategorized as benefits to (1) CHWs, (2) patients, or (3) academic community MTM research. The CHWs perceived that they served as a liaison among the medical provider (prescriber), patient, and MTM pharmacist. Benefits to the patients focused on the integration of CHWs as essential to patient recruitment, especially for those who were reluctant to participate or receive a phone call from a stranger. The major challenges identified were (1) interruptions in workflow and (2) communication between CHWs and the health care practitioners (physicians, nurse practitioners, pharmacists). Specifically, the CHWs universally agreed that they needed more time after receiving patient report, scheduling a visit with the patient, and communicating with the patient's health care provider to better understand the individual's circumstances and needs.

CONCLUSION

This study identified perceived opportunities and challenges faced by CHWs and chronically ill, rural Latinx patients in the acceptance of MTM program. These findings may be useful for all interprofessional health care team members to better understand and appreciate the role of CHWs, while simultaneously enhancing and improving respective medication adherence efforts, and to improve collaborative, academic community programs in the future.

Medication rebates and health disparities: Mind the gap

Compared to white patients in the United States, people of racial and ethnic minority groups face higher rates of chronic disease including diabetes, obesity, stroke, cardiovascular disease and cancer. Minority groups are also less likely to receive medication therapy to manage complications of chronic disease as well as be adherent to these therapies. A recently announced proposed rule by the Department of Health and Human Services Office of the Inspector General (HHS OIG), which would discourage rebates between manufacturers and payers in favor of discounts directly provided to patients, has received significant attention for its anticipated impact on prescription drug pricing and reimbursement in Medicare. This commentary describes the proposed rule and how it may impact adherence among patients of racial minority groups through an illustrative case study and discussion.

Higher Predictive Value Positive for MMA Than ACA MTM Eligibility Criteria Among Racial and Ethnic Minorities: An Observational Study

The objective of this study was to examine positive predictive value (PPV) of medication therapy management (MTM) eligibility criteria under Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial and ethnic groups. The study analyzed Medicare data (2012-2013) for 2 213 594 beneficiaries. Medication utilization issues were determined based on medication utilization measures mostly developed by Pharmacy Quality Alliance. MMA was associated with higher PPV than ACA in identifying individuals with medication utilization issues among non-Hispanic blacks (blacks) and Hispanics than non-Hispanic whites (whites). For example, odds ratio for having medication utilization issues to whites when examining MMA in 2013 and ACA were 1.09 (95% confidence interval [CI] = 1.04-1.15) among blacks, and 1.17 (95% CI = 1.10-1.24) among Hispanics, in the main analysis. Therefore, MMA was associated with 9% and 17% higher PPV than ACA in identifying patients with medication utilization issues among blacks and Hispanics, respectively, than whites.

Disparity Implications of Proposed 2015 Medicare Eligibility Criteria for Medication Therapy Management Services

OBJECTIVES

Previous studies found that racial and ethnic minorities may be less likely than non-Hispanic Whites (Whites) to meet existing Medicare medication therapy management (MTM) eligibility criteria. To address these issues, the Centers for Medicare & Medicaid Services (CMS) proposed alternative Medicare MTM eligibility criteria for 2015. Due to opposition to other Part D reforms proposed simultaneously by various stakeholders, CMS rescinded all proposed reforms. This study was conducted to determine whether non-Hispanic Blacks (Blacks) and Hispanics have lower likelihood of meeting the proposed 2015 Medicare MTM eligibility criteria.

METHODS

This retrospective observational analysis used Medical Expenditure Panel Survey data (2010-2011). The final study sample was comprised of 2,721 Whites (weighted to 37,185,896), 917 Blacks (weighted to 4,665,644), and 538 Hispanics (weighted to 3,532,882). Chi-square tests were used to examine racial and ethnic disparities in meeting proposed 2015 MTM eligibility criteria and each component of proposed 2015 MTM eligibility criteria. In multivariate analysis, a logistic regression model was used to control for population socio-demographic and health-related characteristics.

KEY FINDINGS

Compared to Whites with a proportion of MTM eligibility of 58.82%, the eligible proportion was 57.09% (P=0.20) for Blacks, and 48.97% (P<0.0001) for Hispanics, respectively. According to multivariate logistic regression, odds ratios of meeting MTM eligibility for Blacks and Hispanics compared to Whites were 0.74 (95% Confidence Internal [CI] = 0.62-0.88) and 0.53 (95% CI=0.43-0.67), respectively.

CONCLUSIONS

The proposed 2015 MTM eligibility criteria would not eliminate racial and ethnic disparities in MTM eligibility. Alternative MTM eligibility criteria should be devised.

Coronary artery disease and the contours of pharmaceuticalization

Coronary artery disease (CAD) has dominated mortality for most of the past century, not just in Europe and North America but worldwide. Treatments for CAD, both pharmaceutical and surgical, have become leading sectors of the healthcare economy. This paper focuses on the therapeutic landscape for CAD in the United States. We hope to add texture to the broader conversation of pharmaceuticalization explored in this issue by situating pharmaceutical therapies as just one element in the broader therapeutic terrain, alongside cardiac surgery and interventional cardiology. Patients with CAD must navigate a therapeutic landscape with three intersecting paths: lifestyle change, pharmaceuticals, and surgery. While pharmaceuticals are often seen as a quick fix, a way of avoiding more difficult lifestyle changes, it is surgery and angioplasty that promise patients the quickest fix of all. There also is another option, often overlooked by analysts but popular among physicians and patients: inaction. The U.S. context is often critiqued as a site of excessive treatment with respect to both drugs and procedures, and yet there is deep stratification within it--over-treatment in many populations and under-treatment in others. People who experience the serious risks of CAD do so in a racialized terrain of durable preoccupations with difference and unequal access to care. While the pharmaceuticalization literature disproportionately attends to lifestyle drugs, which some observers consider to be medically inappropriate or unnecessary, CAD does remain the leading cause of death. Thus, the stakes are high. Examination of the pharmaceuticalization of CAD in light of surgical treatments and racial disparities offers a window into the pervasiveness and persuasiveness of pharmaceuticals in an increasingly consumer-driven medicine, as well as the limits of their appeal and their reach.