Running head: MEDICARE PART D ENROLLEES

Quality of Care, Costs, and Utilization of Medicare Part D Enrollees

Nina Naples

University of San Diego

MSNC-507-02A-SU19 - Statistics

Dr. Thidarat Tinnakornsrisuphap

July 8, 2019
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Quality of Care, Costs, and Utilization of Medicare Part D Enrollees

The article “Quality of Care, Health Care Costs, and Utilization Among Medicare Part D

Enrollees With and Without Low-Income Subsidy” provides a well-researched study using

cross-sectional, retrospective, and claims based analysis on evaluating disease specific quality

measures. The evaluated diseases are asthma, chronic obstructive pulmonary disease (COPD),

diabetes, coronary artery disease (CAD), heart failure (HF), Hyperlipidemia (HPL) Hypertension

(HTN), and new episode depression (Buikema, 2012).

The primary author of the article is Julie Priest. She is the Director of U.S. Health

Outcomes at ViiV Healthcare. She also has her master’s in public health and researches health

outcomes, medication adherence, and epidemiology. The primary question of interest in the

article was to identify and evaluate the differences in disease specific quality measures, use of

acceptable therapies, and health care cost and utilization between a set of common conditions

among enrollees overall and by income/subsidy eligibility status (Buikema, 2012). The question

is worth answering because by being able to identify where quality metrics for certain diseases

are not being met, we can avoid these gaps in care. For example, the study outlined that most

Medicare Advantage Part D diabetic patients received their eye exam but only about 43% of

patients did not have the recommended 2 Alc tests throughout the year (Buikema, 2012). If

patients adhere to their treatment and medication, they can improve clinical and economic

outcomes for the aging population.

How the research was conducted

The research was conducted by using cross-sectional, retrospective, and claims based

analysis by using Medicare Part D enrollment eligibility information, as well as medical and

pharmacy claims data obtained from a Medicare Advantage Part D national plan sponsor that
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provides medical and prescription drug benefits (Buikema, 2012). The research was designed to

utilize the claims data to create a quality of care benchmark for the identified common diseases

in a large national cohort of Medicare Part D enrollees (Buikema, 2012). Further analysis will be

done for each specific disease by evaluating quality measures, use of acceptable therapies per

national guidelines, medication adherence, and health care cost and resource utilization

(Buikema, 2012).

The article explained that there was proper use of sampling procedures by making sure

the Medicare Part D enrollees involved in the study were geographically diverse across the

United States (Buikema, 2012). The Medicare Part D patients were separated into groups by

their conditions and low-income status and subsidy eligibility. The condition-based group data

was found in 2006 claims evidence (Buikema, 2012). Each disease was evaluated separately,

therefore patients were able to participate in more than one group if they met both groups

conditions of interest and low-income status. Patients were also identified if they were dually

eligible for both Medicare and Medicaid during 2007, if so, they were classified as low

income/dually eligible (LI/DE) (Buikema, 2012). Those who were not eligible for low income

subsidy, as well as not dually eligible were identified as non-LI/DE (Buikema, 2012).

The research required patients to be enrolled in Medicare Advantage continuously

throughout 2007. They also needed to have a prescription claim in 2007 and have at least one

condition of interest during 2006 (Buikema, 2012). The conditions of interest consisted of

asthma, chronic obstructive pulmonary disease (COPD), diabetes, coronary artery disease

(CAD), heart failure (HF), Hyperlipidemia (HPL) Hypertension (HTN), and new episode

depression; but patients were excluded if they were enrolled in an alternative program, such as an
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all-inclusive care of the elderly or certain special needs, if the geographic region was not

identified in the data or if the patient had invalid costs (Buikema, 2012).

Collected Data, Analysis, and Results

The researched data was collected by a large national Medicare Advantage Part D

sponsor. All patients had to be at least 65 years of age with at least one condition of interest, but

not limited to one. The data was collected from January 1, 2007 to December 31, 2007. The

sample for the final study included 183,213 patients who had at least one condition. The sample

set represents approximately 84% of the Medicare Advantage Part D population who are 65

years of age or older. The most populated conditions of interest were hypertension,

hyperlipidemia, and coronary artery disease. The sample set showed that overall there were less

low income and dually eligible (LI/DE) patients than non-low income and non-dually eligible

(non-LI/DE) patients. The sample also showed that they were significantly more males in the

non-LI/DE than in the LI/DE group.

The results varied based on the analysis of acceptable medication sample,

medication persistence, and medication compliance. The amount of acceptable prescription fills

were defined by national guidelines for each disease (Buikema, 2012). The data ranged from

40% to 96% of patients with at least one prescription fill during the year of 2007 across all

conditions and cohorts. Medication persistence was defined as the percentage of days covered

(PDC), which is the total number of days of supply from the first fill date to the end of the year

divided by the number of days between the first fill date and last day of the year (Buikema,

2012). The LI/DE group had significantly higher achievement of PDC than the non-LI/DE

group. HF, CAD, and HTN had the highest percentage of patients with a PDC. Medication

compliance was calculated based on patients with 2 or more acceptable medication fills and the
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timeliness of the fills between the first and last fill of the year, known as the medication

possession ratio (MPR). Medication compliance was also the highest among HF, CAD, and

HTN. The data found that there was a greater percentage of LI/DE patients than non-LI/DE

patients who received a higher MPR (Buikema, 2012).

Table 1

Acceptable Medication Sample

100
96 95
95
Percentage of Cohort

90
90 88

85
82
80
80

75

70
HF CAD HTN
Condition of Interest

LI/DE Non-LI/DE

Table 2

Medication Persistence (PDC)

90 83.3
80 77.2
69.5 71.2
70 67.9
Percentage of Cohort

62.1
60
50
40
30
20
10
0
HF CAD HTN
Condition of Interest

LI/DE Non-LI/DE
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Table 3

Medication Compliance (MPR)

92 91
90
88 87.2
Percentage of Cohort

86
84 83.3 83 82.5
82
79.8
80
78
76
74
HF CAD HTN
Condition of Interest

LI/DE Non-LI/DE

Conclusions

The main objective of this study was to evaluate the care of specified diseases among

patients enrolled in Medicare Advantage Part D plans. The researched used cross-sectional,

retrospective, and claims based analysis to evaluate disease specific quality measures (Buikema,

2012). The analyzed diseases were asthma, chronic obstructive pulmonary disease (COPD),

diabetes, coronary artery disease (CAD), heart failure (HF), Hyperlipidemia (HPL) Hypertension

(HTN), and new episode depression (Buikema, 2012). The research has shown that despite the

advances in treatment and management of chronic diseases over the past few years, not all

patients receive the appropriate recommended care. Medication adherence is one of the more

neglected forms of recommended care in patients with chronic diseases (Buikema, 2012).

Overall, the treatment and medication adherence was less than desirable while the cost

and utilization rates were significant throughout the evaluated condition of interest. Since the

results show a deficit in care, treatment, and medication adherence, there is a need for patients,
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providers, payers, and health systems to strategize a comprehensive plan to better the quality of

care for the Medicare Part D patients (Buikema, 2012). A more widespread plan can then go on

to improve the clinical and economic outcomes for the future generation of Medicare Advantage

Part D patients.

The results varied among disease when analyzing the quality of care, adherence, and cost

in patients with different income status levels. The quality metrics and utilization rates for

acceptable prescription fills for therapy suggests that the care for Medicare Part D patients is

suboptimal. For example, the study outlined that most Medicare Advantage Part D Asthma and

COPD patients had the lowest rate in acceptable amount of prescription fills throughout the year

(Buikema, 2012).

The study’s limitations were among the Medicare Advantage Part D patient’s income and

subsidy levels. Since LI/DE and non-LI/DE patients differ from each other in terms of subsidy

and socioeconomic status, certain underlying risks and health-related behaviors come into play

(Buikema, 2012). Another limitation was based on the fact that Medicare patients with at least

one condition often times have multiple diagnoses which can affect the health care cost and

utilization data for comorbidities (Buikema, 2012).

Generally the results favored the non-LI/DE patients over the LI/DE patients. However,

the quality metric and utilization rate results for medicate compliance were higher in LI/DE

patients than the non-LI/DE patients (Buikema, 2012). The highest achievement of medication

persistence and compliance was among CAD and HF patients. While the lowest observed

medication persistence and compliance was found in asthma and COPD patients (Buikema,

2012). The results were true for both the LI/DE and non-LI/DE groups. The research found that

the low adherence rates in asthma and COPD patients could be due to the fact that they may wait
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until their symptoms are acute or until their symptoms flare up before they seek treatment. These

poor medication adherence rates can increase the rate of exacerbation in patients (Buikema,

2012). The results of this study can start as a foundation for a much larger scale analysis on the

quality of care provided to Medicare Advantage Part D patients.

Strengths and Weaknesses of the Selected Statistical Methods

The results were trustworthy based on the fact that the research analyzed a large sample

set of Medicare Part D patients who had a large demographic and covered the nation

geographically. The sample set contained 183,213 male and female patients whose ages were a

wide range over 65 years old (Buikema, 2012). Although there were a few limitations to the

research, the results ended with a comprehensive look into how treatment and management of

chronic diseases in Medicare Advantage Part D patients are not as advanced as some may think

or hope. The patients, providers, payers, and health systems must realize that the quality of care

for these conditions of interest need to be evaluated and managed at a higher level of care.

Since the study was conducted by using cross-sectional, retrospective, and claims based

analysis to evaluate disease specific quality measures, the limitation of the claims based data

analysis is used and collected for payment purpose instead of research analysis, the data can

provide a look into the patient’s treatment patterns but it does not give a comprehensive and

accurate look into the patient’s medical history (Buikema, 2012). This can be potentially

improved with health systems implementing electronic health records and being able to provide

statistics based on their patients care. This can deliver a deeper level of insight into the patient’s

medical history, which could then prevent some of the study’s limitations within the research.

Health systems adopting electronic health systems can be a pivotal turning point in how

researchers analyze health related statistics.

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References

Buikema, A, Engel-Nitz, N. M., Cook, C. L., Cantrell, C. R., Priest, J. (2012). Quality of Care,

Health Care Costs, and Utilization Among Medicare Part D Enrollees With and Without

Low-Income Subsidy. Population Health Management. Vol. 15 Issue 2, p101-112. 12p.

DOI: 10.1089/pop.2011.0008.