Using Medicare Part D Data for Research

Medical claims can be a primary data source for translational research. This presentation provides information on Medicare as a source of claims data, including a brief overview of Medicare Part D, brief overview of Part D data, and examples of Medicare Part D studies. This presentation was part of the retreat mini-symposium entitled: Big Data: Medical Claims Data for Translational Research

Medicare Prescription Drug Legislation: What It Means for Rural Beneficiaries

Executive Summary: Congress is currently debating legislation that would not only add a prescription drug benefit to Medicare but create an unprecedented role for private health insurers in delivering all Medicare services. Such changes would have profound effects on the 41 million people covered by Medicare -- particularly the one in four who lives in rural America. Previous studies have shown that rural beneficiaries have different health care needs and delivery systems than their urban counterparts. Indeed, the bills that passed the House and Senate address payments to rural hospitals and other providers. However, less attention has been paid to the rural beneficiary implications of the prescription drug benefit and private plan reforms included in the Medicare legislation. This study does so, through new data analysis and synthesis of existing information. The results of this study underscore the unique challenges that face Medicare’s 9 million rural beneficiaries today and under the Medicare proposals under consideration. New analysis shows that rural beneficiaries are, relative to urban beneficiaries, older, sicker, and poorer and have a greater need for a Medicare drug benefit. They are nearly twice as likely to lack any type of insurance coverage for prescription drugs. However, the design of a Medicare prescription drug benefit is critical to ensuring that the unique needs of Medicare’s rural beneficiaries are met. Rural beneficiaries would be disadvantaged by a Medicare prescription drug benefit that has weak protections for low-income beneficiaries – or excludes them altogether. Their higher incidence of chronic illnesses like arthritis and heart disease would leave them vulnerable to higher prescription drug cost sharing and premiums if private insurers rather than Medicare were to define the benefit. In addition, a prescription drug benefit that relies exclusively on private insurers could create serious access problems for rural beneficiaries. This study shows that private insurers have proven unreliable in rural areas: they are less likely to serve rural areas, and when they do, they are less likely to maintain service over a sustained period of time. Finally, reforms outside the addition of a prescription drug benefit could exacerbate the current inequities caused by Medicare funding of supplemental health benefits only through private plans. Not only do rural beneficiaries have less access to subsidized benefits through private plans, but they would fund these benefits through higher Medicare premiums. The report concludes by recommending that stronger protections for low-income and sicker beneficiaries, a more stable prescription drug delivery system, and a more equitable allocation of Medicare subsidies for supplemental benefits – rather than concentrating them in private plans -- would make the ultimate Medicare legislation more responsive to rural beneficiaries’ circumstances

Racial and ethnic disparities in prescription coverage and medication use

This study compared drug coverage and prescription drug use by race and Hispanic ethnicity for Medicare beneficiaries with three chronic conditions: diabetes, hypertension, or heart disease. We found that among beneficiaries without any drug coverage black persons and Hispanics used 10 to 40 percent fewer medications, on average, than white persons with the same illness, and spent up to 60 percent less in total drug costs. Having drug coverage somewhat lessened these differences although the effect was consistent with only M + C prescription benefits. Substantially lower medication use remained for dually eligible black beneficiaries and Hispanics with employer-sponsored drug benefits

Participation and crowd-out in a Medicare drug benefit: simulation estimates

This article provides information on likely participation in the Medicare prescription drug plan and expected crowd-out. We use a microsimulation model based on data from the MCBS to estimate the costs and benefits of a Medicare drug plan, including the benefits from reductions in risk. The simulations are repeated using different combinations of benefits and subsidies. In addition, the simulations explore the effects of different behavioral parameters for moral hazard (the extent to which participants increase drug spending in response to reduced costs) and risk aversion (the extent to which participants would be willing to pay to avoid risk) to identify the impact of these factors on participation and crowd-out

Caught in between: prescription drug coverage of Medicare beneficiaries near poverty

As Congress continues to debate whether and how to add prescription drug coverage to Medicare, beneficiaries with incomes near the poverty level are in danger of being overlooked. These vulnerable low-income individuals, sometimes labeled the “near poor,” have too much income or too many assets to qualify for public assistance, yet are still quite needy. As a result, they find themselves caught between public programs that are available for the poor and private coverage that is affordable for higher-income beneficiaries

Pharmaceutical Pain Management among Older Adults with Cancer in Nursing Homes

Background: In the mid-1990s, 29.4% of nursing home (NH) residents with cancer suffered from daily pain, and among them 26% failed to receive analgesic medication. Improvements in cancer pain management in NHs have not been re-evaluated since the implementation of pain management quality indicators. Methods: We performed a cross-sectional study using nationwide data on NH resident health from the Minimum Data Set (version 2.0) linked to all-payer pharmacy dispensing records (February 2006–June 2007). Prevalence of pain (daily, less than daily, horrible/excruciating, moderate) and receipt of non-opioid and opioid analgesics were calculated. We used multinomial logistic regression to evaluate resident-level correlates of pain and binomial logistic regression to identify correlates of untreated pain. Results: 8,094 newly-admitted, Medicare-eligible residents had cancer. 65.6% had any pain (28.3% daily, 37.3% less than daily), among whom 13.5% had severe and 61.3% had moderate pain. Women, residents who were bedfast and those with compromised activities of daily living, depressed mood, indwelling catheter, or terminal prognosis were more likely to report pain. More than 17% of residents in daily pain (95% confidence interval [CI], 15.8–18.9%) and 14.2% with horrible/excruciating pain (95% CI, 11.7–16.8%) received no analgesics. Analgesic treatment was negatively associated with age \u3e85 (adjusted odds ratio [aOR]=0.67, 95% CI: 0.55–0.81 versus aged 65–74), impaired cognition (aOR=0.71, 95% CI: 0.61–0.82), presence of feeding tube (aOR=0.75, 95% CI: 0.58–0.97), and use of restraints (aOR=0.50, 95% CI: 0.31–0.81). Conclusion: Untreated pain is still common among NH residents with cancer, and persists despite pain management quality indicators

Medicare Part D and Long-Term Care: A Systematic Review of Quantitative and Qualitative Evidence

BACKGROUND: In the largest overhaul to Medicare since its creation in 1965, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established Part D in 2006 to improve access to essential medication among disabled and older Americans. Despite previous evidence of a positive impact on the general Medicare population, Part D\u27s overall effects on long-term care (LTC) are unknown. OBJECTIVE: The purpose of this systematic review was to evaluate the literature regarding Part D\u27s impact on the LTC context, specifically costs to LTC residents, providers and payers; prescription drug coverage and utilization; and clinical and administrative outcomes. DATA SOURCES: Four electronic databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Business Fulltext Elite and Science Citation Index Expanded], selected US government and non-profit websites, and bibliographies were searched for quantitative and qualitative studies characterizing Part D in the LTC context. Searches were limited to studies that may have been published between 1 January 2006 (date of Part D implementation) and 8 January 2013. STUDY SELECTION: Systematic searches identified 1,624 publications for a three-stage (title, abstract and full-text) review. Included publications were in English language; based in the US; assessed Part D-related outcomes; and included or were directly relevant to LTC residents or settings. News articles, reviews, opinion pieces, letters or commentaries; case reports or case series; simulation or modeling studies; and summaries that did not report original data were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS: A standardized form was used to abstract study type, study design, LTC setting, sources of data, method of data collection, time periods assessed, unit of observation, outcomes and results. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies. RESULTS: Eleven quantitative and eight qualitative studies met inclusion criteria. In the seven years since its implementation, Part D decreased out-of-pocket costs among enrolled nursing home residents and potentially increased costs borne by LTC facilities. Coverage of prescription drugs frequently used by older adults was adequate, except for certain drugs and alternative formulations of importance to LTC residents. The use of medications that raise safety concerns was decreased, but overall drug utilization may have been unaffected. Although there was uncertain impact on clinical outcomes, quantitative studies demonstrated evidence of unintended health consequences. Qualitative studies consistently revealed increased administrative burden among providers. LIMITATIONS: Empirical evidence of Part D\u27s LTC impact was sparse. Due to limitations in available types of data, quantitative studies were generically lacking in methodological rigor. Qualitative studies suffered from lack of clarity of reporting. As future studies use clinical Medicare data, study quality is expected to improve. CONCLUSION: Although LTC-specific policies continue to evolve, it appears that the prescription drug benefit may require further modifications to more effectively provide for LTC residents\u27 unique medication needs and improve their health outcomes. Adjustments may be needed for Part D to be more compatible with LTC prescription drug delivery processes

Predictability of prescription drug expenditures for Medicare beneficiaries

MCBS data are used to analyze the predictability of drug expenditures by Medicare beneficiaries. Predictors include demographic characteristics and measures of health status, the majority derived using CMS\u27 diagnosis cost group/hierarchical condition category (DCG/HCC) risk-adjustment methodology. In prospective models, demographic variables explained 5 percent of the variation in drug expenditures. Adding health status measures raised this figure between 10 and 24 percent of the variation depending on the model configuration. Adding lagged drug expenditures more than doubled predictive power to 55 percent. These results are discussed in the context of forecasting, and risk adjustment for the proposed new Medicare drug benefit

Statin Discontinuation among Nursing Home Residents with Advanced Dementia

Background: Statin use in elderly individuals with life-limiting illness such as advanced dementia is controversial. Objective: To describe factors associated with statin discontinuation and estimate impact of discontinuation on 28-day hospitalizations in nursing home (NH) residents with advanced dementia. Methods: Retrospective cohort study of NH residents ≥ 65 years with recent progression to advanced dementia from 5 large U.S. states drawn from the 2007-2008 Minimum Data Set 2.0. We identified residents using statins. Clinical characteristics and 28-day hospitalization risk were compared for residents discontinuing and continuing statins. Multivariable Cox proportional hazard models identified factors associated with time to statin discontinuation and time to hospitalization. Sensitivity analysis using self-controlled case series examined the role of confounding-by-indication on risk estimation from the cohort approach. Results: Of 10,212 residents with decline to advanced dementia, 16.6% were prescribed statins (n=1,699). Statin users had mean age of 83.1 yrs, 68.9% were female, and mean medication burden was 10.3 (SD 4.8, range 1-31). Over one-third (n=632) discontinued in follow-up. Median time to discontinuation was 36 days after decline to advanced dementia (IQR [25%, 75%]: 12 days, 110 days). After adjustment, factors independently associated with increased hazard of discontinuation included residence in a NH in Florida relative to California, hospitalization in the 30 days prior to decline to advanced dementia, greater medication burden, and having cancer. The 28-day hospitalization risk was higher for residents discontinuing statins compared to continuing (adjusted hazard ratio = 1.78, CI 1.61,2.58). The SCCS estimate for 28-day hospitalization risk following statin discontinuation compared to a 28-day pre-discontinuation control period was lower than the cohort estimate (IRR= 0.79, CI 0.76, 0.83). Conclusion: A significant proportion of nursing home residents with dementia who use statins when they progress to advanced stage disease discontinue use. Hospitalization outcomes following discontinuation differ depending on method of estimation

Pay-for-performance in nursing homes.

Information on the impact of pay-for-performance programs is lacking in the nursing home setting. This literature review (1980-2007) identified 13 prior examples of pay-for-performance programs in the nursing home setting: 7 programs were active as of 2007, while 6 had been terminated. The programs were mostly short-lived, varied considerably in the choice of performance measures and pay incentives, and evaluations of the impact were rare