Disparity implications of Medicare eligibility criteria for medication therapy management services

Racial and ethnic disparities related to the Medicare Part D Medication Therapy Management Program

Medicare's Part D Medication Therapy Management (MTM) programs serve approximately 4.5 million eligible beneficiaries. Prior research suggested that the thresholds to enter Part D MTM programs would disproportionately favor White beneficiaries compared with Black or Hispanic beneficiaries. This article summarizes those initial studies and compares the results with more recent analyses of racial and ethnic differences in MTM program enrollment, which, in general, show higher odds of MTM enrollment for minority beneficiaries compared with White beneficiaries. Disparities in the utilization of comprehensive medication review (CMR), a core MTM service, are also discussed. Although trends vary, disparities exist for various minority groups. For example, Black beneficiaries and Hispanic beneficiaries are less likely to be offered a CMR compared with White beneficiaries. Additionally, minority (Asian, Hispanic, and North American Native) beneficiaries are less likely to receive a CMR after being offered the service compared with White beneficiaries. Black, Hispanic, and Asian beneficiaries are more likely than White beneficiaries to have a longer duration between MTM enrollment and CMR offer. There is also a distinct difference in the type of pharmacist (ie, plan pharmacist, MTM vendor pharmacist, or community pharmacist) completing the CMR for certain racial and ethnic groups. For example, compared with White beneficiaries, Black beneficiaries were less likely to receive a CMR from a community pharmacist, whereas Asian beneficiaries were more likely.

Impact of medication therapy management programs on potentially inappropriate medication use in older adults: A systematic review

BACKGROUND

The use of potentially inappropriate medications (PIMs) is prevalent, costly, and harmful for older adults. These medications are to be avoided among older adults because they generally have (1) a high risk of adverse events in this population and/or (2) limited evidence of benefits in the presence of safer or more effective alternatives. Medication therapy management (MTM) programs can help address PIM use; however, there has not been a synthesis of studies examining the impact of MTM programs on PIM use.

OBJECTIVE

To review published literature evaluating the impact of MTM on PIM use in older adults.

METHODS

A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines using MEDLINE (PubMed) studies were included if they (1) had a Medicare population, (2) were based in the United States, (3) examined an MTM program (ie, used the term "medication therapy management"), (4) focused on the impact of MTM programs on PIM use as the primary outcome, (5) had a randomized controlled trial or an observational study design, and (6) were available in English.

RESULTS

Of 221 articles identified, 31 full-text articles were assessed, and 7 met all inclusion and exclusion criteria. The studies took place in various settings, ranging from single-site tertiary medical centers to multisite outpatient clinics, community pharmacies, and nationwide telehealth MTM providers. Patient populations were majority female sex (ranging from 61% to 71%) and majority White (ranging from 81% to 94%), with a mean age of 73 to 78 years. In 5 of the 7 studies, MTM reduced the use of PIMs; however, 3 did not adjust for confounding or apply a comparator group. Measurement of MTM impacts on PIM use varied across studies. Patient-level and plan-level studies mostly assessed shorter-term PIM usage reduction (4 months or less), whereas studies performed at the provider and institutional level assessed PIM usage reduction trends across consecutive measurement years.

CONCLUSIONS

Based on the current limited evidence, MTM programs in older adults appear to have a positive impact on reducing PIM use. However, evidence was limited by study design, the lack of consistency in outcome measures, and a short follow-up period. Future work should adjust for confounding, apply comparator groups, include longer-term outcomes, and develop a core set of measures that can be consistently applied across studies.

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.

Cost-Effectiveness of Medication Therapy Management Program Across Racial and Ethnic Groups Among Medicare Beneficiaries

OBJECTIVES

Equity and effectiveness of the medication therapy management (MTM) program in Medicare has been a policy focus since its inception. The objective of this study was to evaluate the cost-effectiveness of the Medicare MTM program in improving medication utilization quality across racial and ethnic groups.

METHODS

This study analyzed 2017 Medicare data linked to the Area Health Recourses File. A propensity score was used to match MTM enrollees and nonenrollees, and an incremental cost-effectiveness ratio between the 2 groups was calculated. Effectiveness was measured as the proportion of appropriate medication utilization based on medication utilization measures developed by Pharmacy Quality Alliance. Net monetary benefits were compared across racial and ethnic groups at various societal willingness-to-pay (WTP) thresholds. The 95% confidence intervals were obtained by nonparametric bootstrapping.

RESULTS

MTM dominated non-MTM among the total sample (N = 699 992), as MTM enrollees had lower healthcare costs ($31 135.89 vs $32 696.69) and higher proportions of appropriate medication utilization (87.47% vs 85.31%) than nonenrollees. MTM enrollees had both lower medication costs ($10 681.21 vs $11 003.08) and medical costs ($20 454.68 vs $21 693.61) compared with nonenrollees. The cost-effectiveness of MTM was higher among Black patients than White patients across the WTP thresholds. For instance, at a WTP of $3006 per percentage point increase in effectiveness, the net monetary benefit for Black patients was greater than White patients by $2334.57 (95% confidence interval $1606.53-$3028.85).

CONCLUSIONS

MTM is cost-effective in improving medication utilization quality among Medicare beneficiaries and can potentially reduce disparities between Black and White patients. Expansion of the current MTM program could maximize these benefits.

Racial/ethnic disparities in the enrollment of Medication Therapy Management programs among Medicare beneficiaries with Alzheimer's disease and related dementias

OBJECTIVE

Previous analysis of policy scenarios reported potential disparities in eligibility in the Medicare Medication Therapy Management (MTM) program. With recently released MTM data, this study aimed to determine if racial/ethnic disparities exist in MTM enrollment among Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD).

METHODS

Medicare claims/records (from 2013-2014 and 2016-2017) linked to the Area Health Resources File were examined. Included individuals were patients with ADRD and diabetes, hypertension or hyperlipidemia. The proportions of MTM enrollment were compared between non-Hispanic White (White) patients and racial/ethnic minority groups in descriptive analysis. Racial/ethnic disparities were then examined using a logistic regression adjusting for patient and community characteristics. Disparities across study periods were compared by estimating a logistic regression model with interaction terms between dummy variables for each racial/ethnic minority group and 2016-2017.

RESULTS

In unadjusted analyses, minorities had higher enrollment proportions than Whites. In 2016-2017, for example, enrollment percentages for Whites, Blacks, Hispanics, Asian/Pacific Islanders (Asians) and Others were respectively 14.44%, 16.71%, 19.83%, 16.66%, and 17.78%. In adjusted analyses, Blacks had lower enrollment odds than Whites within all cohorts. In the entire study sample in 2016-2017, for example, Blacks with ADRD had 9% lower odds of MTM enrollment (odds ratio 0.91, 95% confidence interval [CI] = 0.86-0.97) than Whites. These disparities decreased over time among the ADRD sample and all sub-groups. The interaction term between Blacks and 2016-2017, for instance, indicated that disparities were lowered by 11% (odds ratio 1.11, 95% CI = 1.05-1.16) across study periods among those with ADRD.

CONCLUSIONS

Blacks with ADRD, and diabetes, hypertension or hyperlipidemia have lower likelihood of MTM enrollment than Whites. Racial disparities were reduced over time but not eliminated.

A Qualitative Analysis to Understand Perception about Medication-Related Problems among Older Minority Adults in a Historically Black Community

Older adults taking multiple chronic medications experience an increased risk of adverse drug events and other medication-related problems (MRP). Most current literature on medication management involves researcher-driven intervention, yet few studies investigate patients' understanding of MRP in a diverse community setting. This report investigates patients' perception of MRP and patient-centered strategies among a cohort of the older adult group in a historically Black urban community. The study design is qualitative using structured open-ended questions in a multidisciplinary patient-centered focus group. Patients (age 65 years or older) taking seven or more medications were recruited. The group comprises patients, caregivers, pharmacists, health educators, a physician, and a nurse. Recordings of the group discussion are transcribed verbatim and analyzed using thematic content analysis and categorized by codes developed from the social-ecological model. The group reports patient-provider relationships, previous experience, fear of side effects played important roles in medication adherence. There is an unmet need for medication management education and tools to organize complex medication lists from multiple providers. This study provides important insights into MRP experienced by minority older adults and provided researchers with potential strategies for future interventions.

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.

Patterns and predictors of older adult Medicare Part D beneficiaries' receipt of medication therapy management

BACKGROUND

Medicare Part D medication therapy management (MTM) includes an annual comprehensive medication review (CMR) as a strategy to mitigate suboptimal medication use in older adults.

OBJECTIVES

To describe the characteristics of Medicare beneficiaries who were eligible, offered, and received a CMR in 2013 and 2014 and identify potential disparities.

METHODS

This nationally representative cross-sectional study used a 20% random sample of Medicare Part A, B, and D data linked with Part D MTM files. A total of 5,487,343 and 5,822,188 continuously enrolled beneficiaries were included in 2013 and 2014, respectively. CMR use was examined among a subset of 620,164 and 669,254 of these beneficiaries enrolled in the MTM program in 2013 and 2014. Main measures were MTM eligibility, CMR offer, and CMR receipt. The Andersen Behavioral Model of Health Services Use informed covariates selected.

RESULTS

In 2013 and 2014, 505,658 (82%) and 649,201 (97%) MTM eligible beneficiaries were offered a CMR, respectively. Among those, CMR receipt increased from 81,089 (16%) in 2013 to 119,181 (18%) in 2014. The mean age of CMR recipients was 75 years (±7) and the majority were women, White, and without low-income status. In 2014, lower odds of CMR receipt were associated with increasing age (adjusted odds ratio (OR) = 0.99 (95% confidence interval (CI) = 0.994-0.995), male sex (OR = 0.93, 95% CI = 0.926-0.951), being any non-White race/ethnicity except Black, dual-Medicaid status (OR = 0.64, 95% CI = 0.626-0.650), having a hospitalization (OR = 0.87, 95% CI = 0.839-0.893) or emergency department visit (OR = 0.67, 95% CI = 0.658-0.686), and number of comorbidities (OR = 0.90, 95% CI = 0.896-0.905).

CONCLUSIONS

CMR offers and completion rates have increased, but disparities in CMR receipt by age, sex, race, and dual-Medicaid status were evident. Changes to MTM targeting criteria and CMR offer strategies may be warranted to address disparities.

Predictive Value Positive of MTM Eligibility Criteria under MMA and ACA in Identifying Individuals with Medication Utilization Issues

OBJECTIVES

To compare the predictive value positives (PVP) of medication therapy management eligibility criteria under the Medicare Modernization Act (MMA) and Affordable Care Act (ACA) in identifying individuals with medication utilization issues (MUI).

METHODS

This is a retrospective analysis of Medicare database (2012-2013). MUI were determined based on medication utilization measures related to Medicare Part D Star Ratings. PVP or proportions of individuals with MUI were compared between individuals eligible for MTM under MMA and ACA. Need-based and demand-based logistic regression was used to adjust for patient characteristics. MTM eligibility thresholds in 2009 and 2013 and proposed 2015 MTM eligibility thresholds under MMA were examined. Main/sensitivity/disease-specific analyses were conducted to cover the range of eligibility thresholds and combinations.

KEY FINDINGS

MMA has higher PVP in identifying patients with MUI than ACA. Proportions of individuals with MUI were higher based on MMA than ACA (e.g., 74.96% for 2009 MMA, 73.51% for 2013 MMA, and 62.46% for proposed 2015 MMA vs. 52.17% for ACA in main analysis; P<0.05). Adjusted findings were similar. For example, based on the demand-based model in the main analysis, the odds ratios were 2.474 (95% CI: 2.454-2.494) for 2013 MMA in comparison to ACA. These numbers indicate that the MMA MTM eligibility criteria for 2013 had 147.4% higher PVP in identifying patients with MUI than ACA. Similar patterns were found in most sensitivity and disease-specific analyses.

CONCLUSIONS

MMA has higher PVP than ACA in identifying patients with MUI. This study may inform the government on future MTM policy.

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.

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.

Racial and ethnic disparities in meeting MTM eligibility criteria among patients with asthma

BACKGROUND

Asthma is one of the most frequently targeted chronic diseases in the medication therapy management (MTM) programs of the Medicare prescription drug (Part D) benefits. Although racial and ethnic disparities in meeting eligibility criteria for MTM services have been reported, little is known about whether there would be similar disparities among adults with asthma in the United States.

METHODS

Adult patients with asthma (age ≥ 18) from Medical Expenditure Panel Survey (2011-2012) were analyzed. Bivariate analyses were conducted to compare the proportions of patients who would meet Medicare MTM eligibility criteria between non-Hispanic Blacks (Blacks), Hispanics and non-Hispanic Whites (Whites). Survey-weighted logistic regression was performed to adjust for patient characteristics. Main and sensitivity analyses were conducted to cover the entire range of the eligibility thresholds used by Part D plans in 2011-2012.

RESULTS

The sample included 4,455 patients with asthma, including 2,294 Whites, 1,218 Blacks, and 943 Hispanics. Blacks and Hispanics had lower proportions of meeting MTM eligibility criteria than did Whites (P < 0.001). According to the main analysis, Blacks and Hispanics had 36% and 32% lower, respectively, likelihood of MTM eligibility than Whites (odds ratio [OR]: 0.64, 95% confidence interval [CI]: 0.45-0.90; OR: 0.68, 95% CI: 0.47-0.98, respectively). Similar results were obtained in sensitivity analyses.

CONCLUSIONS

There are racial and ethnic disparities in meeting Medicare Part D MTM eligibility criteria among adult patients with asthma. Future studies should examine the implications of such disparities on health outcomes of patients with asthma and explore alternative MTM eligibility criteria.

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.

Impact of Medicare Part D on Racial Disparities in Adherence to Cardiovascular Medications Among the Elderly

Medicare Part D improved medication adherence among the elderly, but to date, its effect on disparities in adherence remains unknown. We estimated Part D impact on racial/ethnic disparities in adherence to cardiovascular medications among seniors, using pooled data from the Medical Expenditure Panel Survey (2002-2010) on 14,221 Medicare recipients (65+ years) and 3,456 near-elderly controls (60-64 years). Study sample included White, Black, or Hispanic respondents who used at least one cardiovascular medication. Twelve-month adherence was measured as having an overall proportion of days covered ≥80%. Adherence disparities were defined according to the Institute of Medicine framework. Using difference-in-differences logistic regression, we found Part D to be associated with a 16-percentage-point decrease in the White-Hispanic disparity in overall adherence among seniors, net of the change among controls. Black-White disparities worsened only among men, by 21 percentage points. Increasing access and improving quality of medication use among disadvantaged seniors should remain a policy priority.

Potential Health Implications of Medication Therapy Management Eligibility Criteria in the Patient Protection and Affordable Care Act Across Racial and Ethnic Groups

BACKGROUND

The Medicare Prescription Drug, Improvement, and Modernization Act requires Part D plans to establish programs to provide medication therapy management (MTM) services starting from 2006. MTM services have been found to improve patient outcomes from pharmacotherapy, reduce emergency room visits and hospitalizations, and reduce health care costs in a cost-effective fashion. However, previous research found that non-Hispanic blacks (blacks) and Hispanics may be less likely to be eligible for MTM services than non-Hispanic whites (whites) among the Medicare population, according to current Medicare MTM eligibility criteria. This finding is because Medicare MTM eligibility criteria are predominantly based on medication use and costs, and blacks and Hispanics tend to use fewer prescription medications and incur lower prescription medication costs. The Patient Protection and Affordable Care Act (PPACA) laid out a set of MTM eligibility criteria for eligible entities to target patients for MTM services: "(1) take 4 or more prescribed medications ...; (2) take any 'high risk' medications; (3) have 2 or more chronic diseases ... or (4) have undergone a transition of care, or other factors ... that are likely to create a high risk of medication-related problems."

OBJECTIVES

To (a) examine racial/ethnic disparities in meeting the eligibility criteria for MTM services in PPACA among the Medicare population and (b) determine whether there would be greater disparities in health and economic outcomes among MTM-ineligible than MTM-eligible groups.

METHODS

This was a retrospective cross-sectional analysis of the Medicare Current Beneficiaries Survey (2007-2008). To determine medication characteristics, the U.S. Food and Drug Administration's Electronic Orange Book was also used. Proportions of the population eligible for MTM services based on PPACA MTM eligibility criteria were compared across racial and ethnic groups using a chi-square test; a logistic regression model was used to adjust for population sociodemographic and health characteristics. Health and economic outcomes examined included health status (self-perceived good health status, number of chronic diseases, activities of daily living [ADLs], and instrumental activities of daily living [IADLs]), health services utilization and costs (physician visits, emergency room visits, and total health care costs), and medication use patterns (generic dispensing ratio). To determine difference in disparities across MTM eligibility categories, difference-in-differences regressions of various functional forms were employed, depending on the nature of the dependent variables. Interaction terms between the dummy variables for minority groups (e.g., blacks or Hispanics) and MTM eligibility were included to test whether disparity patterns varied between MTM-ineligible and MTM-eligible individuals.

RESULTS

The sample consisted of 12,966 Medicare beneficiaries, of which 11,161 were white, 930 were black, and 875 were Hispanic. Of the study sample, 9,992 whites (86.4%), 825 blacks (86.3%), and 733 Hispanics (80.6%) were eligible for MTM. The difference between whites and Hispanics was significant (P  less than  0.050), and the difference between whites and blacks was not significant (P  greater than 0.050). In multivariate analyses, significant disparity in eligibility for MTM services was found only between Hispanics and whites (odds ratio [OR] = 0.59; 95% CI = 0.43-0.82) but not between blacks and whites (OR = 0.78; 95% CI = 0.55-1.09). Disparities were greater among the MTM-ineligible than the MTM-eligible populations in self-perceived health status, ADLs, and IADLs for both blacks and Hispanics compared with whites. When analyzing the number of chronic conditions, the number and costs of physician visits, and total health care costs, the authors of this study found lower racial and ethnic disparities among the ineligible population than the eligible population.

CONCLUSIONS

Hispanics are significantly less likely than whites to qualify for MTM among the Medicare population, according to MTM eligibility criteria stipulated in the PPACA. PPACA MTM eligibility criteria may aggravate existing racial and ethnic disparities in health status but may remediate racial and ethnic disparities in health services utilization. Alternative MTM eligibility criteria other than PPACA MTM eligibility criteria may be needed to improve the efficiency and equity of access to Medicare Part D MTM programs.

Trends in Medicare Part D Medication Therapy Management Eligibility Criteria

BACKGROUND

To increase the enrollment rate of medication therapy management (MTM) programs in Medicare Part D plans, the US Centers for Medicare & Medicaid Services (CMS) lowered the allowable eligibility thresholds based on the number of chronic diseases and Part D drugs for Medicare Part D plans for 2010 and after. However, an increase in MTM enrollment rates has not been realized.

OBJECTIVES

To describe trends in MTM eligibility thresholds used by Medicare Part D plans and to identify patterns that may hinder enrollment in MTM programs.

METHODS

This study analyzed data extracted from the Medicare Part D MTM Programs Fact Sheets (2008-2014). The annual percentages of utilizing each threshold value of the number of chronic diseases and Part D drugs, as well as other aspects of MTM enrollment practices, were analyzed among Medicare MTM programs that were established by Medicare Part D plans.

RESULTS

For 2010 and after, increased proportions of Medicare Part D plans set their eligibility thresholds at the maximum numbers allowable. For example, in 2008, 48.7% of Medicare Part D plans (N = 347:712) opened MTM enrollment to Medicare beneficiaries with only 2 chronic disease states (specific diseases varied between plans), whereas the other half restricted enrollment to patients with a minimum of 3 to 5 chronic disease states. After 2010, only approximately 20% of plans opened their MTM enrollment to patients with 2 chronic disease states, with the remaining 80% restricting enrollment to patients with 3 or more chronic diseases.

CONCLUSION

The policy change by CMS for 2010 and after is associated with increased proportions of plans setting their MTM eligibility thresholds at the maximum numbers allowable. Changes to the eligibility thresholds by Medicare Part D plans might have acted as a barrier for increased MTM enrollment. Thus, CMS may need to identify alternative strategies to increase MTM enrollment in Medicare plans.

Contingent valuation and pharmacists' acceptable levels of compensation for medication therapy management services

BACKGROUND

Pharmacists' acceptable level of compensation for medication therapy management (MTM) services needs to be determined using various economic evaluation techniques.

OBJECTIVES

Using contingent valuation method, determine pharmacists' acceptable levels of compensation for MTM services.

METHODS

A mailing survey was used to elicit Tennessee (U.S.) pharmacists' acceptable levels of compensation for a 30-minute MTM session for a new patient with 2 medical conditions, 8 medications, and an annual drug cost of $2000. Three versions of a series of double-bounded, closed-ended, binary discrete choice questions were asked of pharmacists for their willingness to accept (WTA) for an original monetary value ($30, $60, or $90) and then follow-up higher or lower value depending on their responses to the original value. A Kaplan-Meier approach was taken to analyze pharmacists' WTA, and Cox's proportional hazards model was used to examine the effects of pharmacist characteristics on their WTA.

RESULTS

Three hundred and forty-eight pharmacists responded to the survey. Pharmacists' WTA for the given MTM session had a mean of $63.31 and median of $60. The proportions of pharmacists willing to accept $30, $60, and $90 for the given MTM session were 30.61%, 85.19%, and 91.01%, respectively. Pharmacists' characteristics had statistically significant association with their WTA rates.

CONCLUSIONS

Pharmacists' WTA for the given MTM session is higher than current Medicare MTM programs' compensation levels of $15-$50 and patients' willingness to pay of less than $40. Besides advocating for higher MTM compensation levels by third-party payers, pharmacists also may need to charge patients to reach sufficient compensation levels for MTM services.

Historical trend of racial and ethnic disparities in meeting Medicare medication therapy management eligibility in non-Medicare population

BACKGROUND

Prior research examining racial and ethnic disparities in meeting Medicare medication therapy management (MTM) eligibility criteria among the non-Medicare population suggests minorities have lower likelihood of being eligible than non-Hispanic Whites (Whites). However, such research has not examined trends in disparities and whether these disparities may be expected to decrease over time based on historical data.

OBJECTIVES

To examine trends in MTM eligibility disparities among the non-Medicare population from 1996-1997 to 2009-2010.

METHODS

This retrospective observational analysis used Medical Expenditure Panel Survey data from the two study periods. The MTM eligibility criteria used by health insurance plans in 2008 and 2010 were analyzed. Trends in disparities were examined by including interaction terms between dummy variables for 2009-2010 and non-Hispanic Blacks (Blacks)/Hispanics in a logistic regression. Interaction effects were estimated on both the multiplicative and additive terms. Main and sensitivity analyses were conducted to represent the ranges of the Medicare MTM eligibility thresholds used by health insurance plans.

RESULTS

According to the main analysis, Blacks and Hispanics were less likely to be eligible than Whites for both sets of eligibility criteria in 1996-1997 and in 2009-2010. Trend analysis for both sets of criteria found that on the multiplicative term, there were generally no significant changes in disparities between Whites and Blacks/Hispanics from 1996-1997 to 2009-2010. Interaction on the additive term found evidence that disparities between Whites and Blacks/Hispanics may have increased from 1996-1997 to 2009-2010 (e.g., in the main analysis between Whites and Hispanics for 2010 eligibility criteria: difference in odds = -0.03, 95% CI: [-0.03]-[-0.02]).

CONCLUSIONS

Racial and ethnic minorities in the non-Medicare population experience persistent and often increasing disparities in meeting MTM eligibility criteria. Drug benefit plans should take caution when using elements of Medicare MTM eligibility criteria.

Effects of medicare part d on disparity implications of medication therapy management eligibility criteria

BACKGROUND

Previous studies have shown that there were greater racial and ethnic disparities among individuals who were ineligible for medication therapy management (MTM) services than among MTM-eligible individuals before the implementation of Medicare Part D in 2006.

OBJECTIVE

To determine whether the implementation of Medicare Part D in 2006 correlates to changes in racial and ethnic disparities among MTM-ineligible and MTM-eligible beneficiaries.

METHODS

Data from the Medicare Current Beneficiary Survey were analyzed in this retrospective observational analysis. To examine potential racial and ethnic disparities, non-Hispanic whites were compared with non-Hispanic blacks and Hispanics. Three aspects of disparities were analyzed, including health status, health services utilization and costs, and medication utilization patterns. A generalized difference-in-differences analysis was used to examine the changes in difference in disparities between MTM-ineligible and MTM-eligible individuals from 2004-2005 to 2007-2008 relative to changes from 2001-2002 and 2004-2005. Various multivariate regressions were used based on the types of dependent variables. A main analysis and several sensitivity analyses were conducted to represent the ranges of MTM eligibility thresholds used by Medicare Part D plans in 2010.

RESULTS

The main analysis showed that Part D implementation was not associated with reductions in greater racial and ethnic disparities among MTM-ineligible than MTM-eligible Medicare beneficiaries. The main analysis suggests that after Part D implementation, Medicare MTM eligibility criteria may not consistently improve the existing racial and ethnic disparities in health status, health services utilization and costs, and medication utilization. By contrast, several sensitivity analyses showed that Part D implementation did correlate with a significant reduction in greater racial disparities among the MTM-ineligible group than the MTM-eligible group in activities of daily living and in instrumental activities of daily living. Part D implementation may be also associated with a reduction in greater ethnic disparities among the MTM-ineligible group than the MTM-eligible groups in the costs of physician visits.

CONCLUSION

Part D implementation was not associated with consistent reductions in the disparity implications of the Medicare MTM eligibility criteria. The main analysis showed that Part D implementation was not associated with a reduction in disparities associated with MTM eligibility, although several sensitivity analyses did show reductions in disparities in specific aspects. Future research should explore alternative Medicare MTM eligibility criteria to eliminate racial and ethnic disparities among the Medicare population.

Predictors of medication-related problems among medicaid patients participating in a pharmacist-provided telephonic medication therapy management program

STUDY OBJECTIVE

To identify predictors of medication-related problems (MRPs) among Medicaid patients participating in a telephonic medication therapy management (MTM) program.

DESIGN

Retrospective analysis of data from patients enrolled in a previously published study.

DATA SOURCES

Two Medicaid administrative claims file databases (for health care utilization and prescription dispensing information) and one pharmacy organization file for MTM program information.

PATIENTS

Seven hundred twelve adult Medicaid patients who participated in a statewide pharmacist-provided telephone-based MTM program and who received an initial medication therapy review.

MEASUREMENTS AND MAIN RESULTS

The primary dependent variable was the number of MRPs detected during the initial medication therapy review. Secondary dependent variables were the detection of one or more MRPs related to indication, effectiveness, safety, and adherence. Predictor variables were selected a priori that, from the literature and our own practice experiences, were hypothesized as being potentially associated with MRPs: demographics, comorbidities, medication use, and health care utilization. Bivariate analyses were performed, and multivariable models were constructed. All predictor variables with significant associations (defined a priori as p<0.1) with the median number of MRPs detected were then entered into a three-block multiple linear regression model. The overall model was significant (p<0.001, R(2)  = 0.064). Significant predictors of any MRPs (p<0.05) were total number of medications, obesity, dyslipidemia, and one or more emergency department visits in the past 3 months. For indication-related MRPs, the model was significant (p<0.001, R(2)  = 0.049), and predictors included female sex, obesity, dyslipidemia, and total number of medications (p<0.05). For effectiveness-related MRPs, the model was significant (p<0.001, R(2)  = 0.054), and predictors included bone disease and dyslipidemia (p<0.05). For safety-related MRPs, the model was significant (p<0.001, R(2)  = 0.046), and dyslipidemia was a predictor (p<0.05). No significant predictors of adherence-related MRPs were identified.

CONCLUSION

This analysis supports the relative importance of number of medications as a predictor of MRPs in the Medicaid population and identifies other predictors. However, given the models' low R(2) values, these findings indicate that other unknown factors are clearly important and that criteria commonly used for determining MTM eligibility may be inadequate in identifying appropriate patients for MTM in a Medicaid population.

Potential effects of racial and ethnic disparities in meeting Medicare medication therapy management eligibility criteria

OBJECTIVE

Medication therapy management (MTM) has the potential to play an instrumental role in reducing racial and ethnic disparities in health care. However, previous research has found that Blacks and Hispanics are less likely to be eligible for MTM. The purpose of the current study was to examine the potential effects of MTM eligibility criteria on racial and ethnic disparities in health outcomes.

METHODS

The current study is a retrospective cross-sectional analysis of the Medicare Current Beneficiary Survey Cost and Use files for the years 2007 and 2008. A difference-in-differences model was used to compare disparities in outcomes between ineligible and eligible beneficiaries according to MTM eligibility criteria in 2010. This was achieved by including in regression models interaction terms between dummy variables for Blacks/Hispanics and MTM eligibility criteria. Interaction terms were interpreted on both multiplicative and additive terms. Various regression models were used depending on the types of variables.

KEY FINDINGS

Whites were more likely to report self-perceived good health status than Blacks and Hispanics among both MTM-eligible and MTM-ineligible populations. Disparities were greater among MTM-ineligible than MTM-eligible populations (e.g., on additive term, difference in odds=1.94 and P<0.01 for Whites and Blacks; difference in odds=2.86 and P<0.01 for Whites and Hispanics). A few other measures also exhibited significant patterns.

CONCLUSIONS

MTM eligibility criteria may exacerbate racial and ethnic disparities in health status and some measures of health services utilizations and costs and medication utilization. Future research should examine strategies to remediate the effects of MTM eligibility criteria on disparities.

Receipt of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers among Medicare Beneficiaries with Diabetes and Hypertension

OBJECTIVES

The proportion of patients with diabetes and hypertension receiving angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACE/ARB), is one of the quality measures for medication management employed by the Centers for Medicare and Medicaid Services to rate Medicare Part D plans. The objectives of this study were to determine the rate and predictors of receiving ACE/ARB in physician office and outpatient visits made by Medicare beneficiaries with diabetes and hypertension.

METHODS

The study population was Medicare beneficiaries with diabetes and hypertension from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Outpatient Department, from 2007 to 2009. Predictors of receiving ACE/ARB were determined using bivariate and multivariate logistic regression analysis.

KEY FINDINGS

Of the 6,311 Medicare outpatient and physician office visits with hypertension and diabetes, 40.70% patient visits were associated with receiving ACE/ARB. Bivariate analysis found that higher proportions of ACE/ARB were received during visits made to primary care physicians compared to visits to non-primary care physicians (48.39% vs. 32.56%; p<0.05). Adjusted multivariate analyses indicated that ACE/ARB were more likely to be received during visits to primary care physicians than visits to non-primary care physicians (odds ratio [OR]: 1.96; 95% confidence interval [CI]: 1.59-2.43), and ACE/ARB were more likely to be received during visits by patients residing in zip codes with median household income within Quartile 2 ($32,794-$40,626), compared to visits by patients residing in zip codes with median household income within Quartile 1 (< $32,793, OR: 1.45; 95% CI: 1.13-1.87).

CONCLUSIONS

Fewer than half of the patient visits were associated with receiving ACE/ARB. Promoting evidence-based medicine and increasing access to primary care may have the potential to increase the rates of receiving ACE/ARB in this population.

Potential health implications of racial and ethnic disparities in meeting MTM eligibility criteria

BACKGROUND

Previous studies have found that racial and ethnic minorities would be less likely to meet the Medicare eligibility criteria for medication therapy management (MTM) services than their non-Hispanic White counterparts.

OBJECTIVES

To examine whether racial and ethnic disparities in health status, health services utilization and costs, and medication utilization patterns among MTM-ineligible individuals differed from MTM-eligible individuals.

METHODS

This study analyzed Medicare beneficiaries in 2004-2005 Medicare Current Beneficiary Survey. Various multivariate regressions were employed depending on the nature of dependent variables. Interaction terms between the dummy variables for Blacks (and Hispanics) and MTM eligibility were included to test whether disparity patterns varied between MTM-ineligible and MTM-eligible individuals. Main and sensitivity analyses were conducted for MTM eligibility thresholds for 2006 and 2010.

RESULTS

Based on the main analysis for 2006 MTM eligibility criteria, the proportions for self-reported good health status for Whites and Blacks were 82.82% vs. 70.75%, respectively (difference = 12.07%; P < 0.001), among MTM-ineligible population; and 56.98% vs. 52.14%, respectively (difference = 4.84%; P = 0.31), among MTM-eligible population. The difference between these differences was 7.23% (P < 0.001). In the adjusted logistic regression, the interaction effect for Blacks and MTM eligibility had an OR of 1.57 (95% Confidence Interval, or CI = 0.98-2.52) on multiplicative term and difference in odds of 2.38 (95% CI = 1.54-3.22) on additive term. Analyses for disparities between Whites and Hispanics found similar disparity patterns. All analyses for 2006 and 2010 eligibility criteria generally reported similar patterns. Analyses of other measures did not find greater racial or ethnic disparities among the MTM-ineligible than MTM-eligible individuals.

CONCLUSIONS

Disparities in MTM eligibility may aggravate existing racial and ethnic disparities in health outcomes. However, disparities in MTM eligibility may not aggravate existing disparities in health services utilization and costs and medication utilization patterns. Future studies should examine the effects of Medicare Part D on these disparities.

Historical trend of disparity implications of Medicare MTM eligibility criteria

BACKGROUND

Non-Hispanic Blacks (Blacks) and Hispanics have a lower likelihood of being eligible for medication therapy management (MTM) services than do non-Hispanic Whites (Whites) based on Medicare MTM eligibility criteria.

OBJECTIVES

To determine whether MTM eligibility criteria would perform differently over time, this study examined the trend of MTM disparities from 1996-1997 to 2007-2008.

METHODS

The study populations were Medicare beneficiaries from the Medical Expenditure Panel Survey. Proportions and the odds of MTM eligibility were compared between Whites and ethnic minorities. The trend of disparities was examined by including in logistic regression models interaction terms between dummy variables for the minority groups and 2007-2008. MTM eligibility thresholds for 2008 and 2010-2011 were analyzed. Main and sensitivity analyses were conducted to represent the entire range of the eligibility criteria.

RESULTS

This study found no statistical significant racial or ethnic disparities associated with the MTM eligibility criteria for 2008 among the Medicare population during 1996-1997. However, racial disparities associated with 2010-2011 MTM eligibility criteria were significant according to multivariate analyses among the Medicare population during 1996-1997. During 2007-2008, both racial and ethnic disparities associated with both 2008 MTM eligibility criteria and 2010-2011 eligibility criteria were generally significant. Disparity patterns did not exhibit a statistically significant change from 1996-1997 to 2007-2008.

CONCLUSIONS

Racial and ethnic disparities in meeting MTM eligibility criteria may not decrease over time unless MTM eligibility criteria are changed.

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

The emphasis on eliminating racial and ethnic disparities in healthcare has received national attention, with various policy initiatives addressing this problem and proposing solutions. However, in the current economic era requiring tight monetary constraints, emphasis is increasingly being placed on economic efficiency, which often conflicts with the equality doctrine upon which many policies have been framed. The authors' review aims to highlight the disparity implications of one such policy provision - the predominantly utilization-based eligibility criteria for medication therapy management services under Medicare Part D - by identifying studies that have documented racial and ethnic disparities in health status and the use of and spending on prescription medications. Future design and evaluation of various regulations and legislations employing utilization-based eligibility criteria must use caution in order to strike an equity-efficiency balance.

Racial and ethnic disparities in influenza vaccinations among community pharmacy patients and non-community pharmacy respondents

BACKGROUND

Since 2009, pharmacists in all 50 states in the U.S. have been authorized to administer vaccinations.

OBJECTIVES

This study examined racial and ethnic disparities in the reported receipt of influenza vaccinations within the past year among noninstitutionalized community pharmacy patients and non-community pharmacy respondents.

METHODS

The 2009 Medical Expenditure Panel Survey was analyzed. The sample consisted of respondents aged 50 years or older, as per the 2009 recommendations by the Advisory Committee on Immunization Practices. Bivariate and multivariate logistic regression analyses were conducted to examine the influenza vaccination rates and disparities in receiving influenza vaccinations within past year between non-Hispanic Whites (Whites), non-Hispanic Blacks (Blacks) and Hispanics. The influenza vaccination rates between community pharmacy patients and non-community pharmacy respondents were also examined.

RESULTS

Bivariate analyses found that among the community pharmacy patients, a greater proportion of Whites reported receiving influenza vaccinations compared to Blacks (60.9% vs. 49.1%; P < 0.0001) and Hispanics (60.9% vs. 51.7%; P < 0.0001). Among non-community pharmacy respondents, differences also were observed in reported influenza vaccination rates among Whites compared to Blacks (41.0% vs. 24.3%; P < 0.0001) and Hispanics (41.0% vs. 26.0%; P < 0.0001). Adjusted logistic regression analyses found significant racial disparities between Blacks and Whites in receiving influenza vaccinations within the past year among both community pharmacy patients (odds ratio [OR]: 0.81; 95% CI: 0.69-0.95) and non-community pharmacy respondents (OR: 0.66; 95% CI: 0.46-0.94). Sociodemographic characteristics and health status accounted for the disparities between Hispanics and Whites. Overall, community pharmacy patients reported higher influenza vaccination rates compared to non-community pharmacy respondents (59.0% vs. 37.2%; P < 0.0001).

CONCLUSION

Although influenza vaccination rates were higher among community pharmacy patients, there were racial disparities in receiving influenza vaccinations among both community pharmacy patients and non-community pharmacy respondents. Increased emphasis on educational campaigns among pharmacists and their patients, especially minorities, may be needed.

Racial and ethnic disparities in meeting Part D MTM eligibility criteria among the non-Medicare population

OBJECTIVE To determine whether racial and ethnic minorities were less likely to meet the Medicare Part D eligibility criteria for medication therapy management (MTM) services compared with whites among the adult non-Medicare population, because some non-Medicare health plans have followed the Medicare example. DESIGN Cross-sectional observational study. SETTING United States, 2007-08. PATIENTS 16,691 white, 5,923 black, and 9,242 Hispanic adults (&gt;17 years) among the non-Medicare population. INTERVENTION Analysis of the Medical Expenditure Panel Survey. MTM eligibility criteria used by Part D plans in 2008 and 2010-11 were examined. Main and sensitivity analyses were conducted to represent the entire range of the eligibility thresholds used by Part D plans. Analyses also were conducted among individuals with heart disease, diabetes, and hypertension. MAIN OUTCOME MEASURES Proportions and odds of patients meeting Part D MTM eligibility criteria. RESULTS According to the main analysis examining 2008 eligibility criteria, whites had a higher proportion of eligible individuals than did blacks (3.73% vs. 2.57%) and Hispanics (1.53%, P &lt; 0.05 for both comparisons). According to survey-weighted logistic regression adjusting for patient characteristics, blacks and Hispanics had odds ratios for MTM eligibility of 0.60 (95% CI 0.46-0.79) and 0.54 (0.40-0.72), respectively, compared with whites. Sensitivity analyses, analyses examining 2010-11 eligibility criteria, and analyses among individuals with heart disease, diabetes, and hypertension produced similar findings. CONCLUSION Racial and ethnic minorities have lower odds for meeting Part D MTM eligibility criteria than whites among the adult non-Medicare population. MTM eligibility criteria need to be modified to address these disparities.

Should Medicare rely on high drug spending as a criterion for medication therapy management programmes?

Objectives

The goal of Medicare Part D medication therapy management programmes (MTMPs) is to optimize medication use by beneficiaries. The Centers for Medicare & Medicaid Services require prescription drug plans (PDPs) to consider numbers of chronic medications and conditions, and total Part D spending when targeting beneficiaries for MTMPs. However, there is no explicit evidence base establishing these criteria. The objectives were to examine the associations of Part D spending with medication use and adherence among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD).

Methods

This retrospective cross-sectional study used a 5% random sample of Medicare beneficiaries with COPD enrolled in stand-alone PDPs and Medicare Parts A and B in 2006–2007 (n = 72 912). Maintenance medication use and adherence for COPD were measured in three domains: discontinuation, duration of therapy and proportion of days covered.

Key findings

Proportions of beneficiaries using COPD maintenance medications increased with Part D spending, from 33.4% (quintile 1) to 60.5% (quintile 5), after covariant adjustment. Among maintenance medication users, the adjusted proportions of beneficiaries exhibiting better adherence also increased with spending, with the top 20% of spenders having the highest proportion of beneficiaries exhibiting good adherence. Adjusted proportions of beneficiaries discontinuing medications decreased with increased Part D spending.

Conclusions

The Part D MTMP spending criterion (US$4000 in 2007; US$3000 in 2010) may be an inappropriate target for identifying Medicare beneficiaries in need of adherence counselling. Findings suggest higher spenders may have learned healthy adherence behaviours, whereas lower spenders may be prone to discontinue medication and/or demonstrate poor adherence behaviours.

Pharmacists' acceptable levels of compensation for MTM services: a conjoint analysis

BACKGROUND

The Medicare Modernization Act of 2003 requires prescription drug plans to provide medication therapy management (MTM) services to Medicare beneficiaries who are at high risk for inappropriate use of medications. However, inadequate compensation has been a barrier for MTM expansion among pharmacists.

OBJECTIVES

The objective of this study was to determine pharmacists' acceptable levels of compensation for MTM services.

METHODS

A preference-based fractional factorial design of conjoint analysis was used by surveying 1524 active pharmacists in Tennessee. Pharmacists were asked to select between packages (scenarios) of MTM services that represented combinations of MTM attributes (characteristics). The MTM attributes included type of patient (new or returning), patient's number of chronic conditions (1, 3, or 6), patient's number of medications (4, 8, or 16), patient's annual drug costs ($2000, $3000, or $4000), service duration (15 minutes, 30 minutes, or 45 minutes), and price of MTM services ($30, $60, or $120). A survival analysis model was used to predict pharmacists' willingness to select 1 versus another MTM service package. Pharmacists' acceptable level of compensation was estimated as the marginal rate of substitution between the parameter estimates of an attribute and the price attribute of MTM.

RESULTS

The parameter estimates were -0.0303 (P<.0001) for service duration and 0.0210 (P<.0001) for price of MTM services, respectively, so pharmacists were willing to accept $1.44/min (0.0303/0.0210), or $86.4/h, for MTM services. Pharmacists' characteristics were associated significantly with their acceptable levels of compensation: years of practice was associated with a higher need for compensation, pharmacy ownership (vs nonowner) associated with a lower need, and having provided MTM previously (vs having not provided MTM) was associated with a higher need.

CONCLUSIONS

Pharmacists' acceptable level of compensation is in the higher part of current ranges from $30 to $100/h. To increase participation in MTM services, pharmacist compensation needs to be increased. Future studies might continue to corroborate the generalizability of findings from this study.