Abstract
Background: Reaching a drug benefit threshold (DBT) (e.g. the Medicare donut hole) has been associated with poor health outcomes. This risk may be greater for those who repeatedly reach the DBT; however there is little information that characterizes this group of Medicare Advantage beneficiaries. We describe a population of beneficiaries who repeatedly reach the DBT over the first two years of Medicare Part D in order to determine if some might benefit from anticipatory care management.
Methods: We developed a historical cohort of 27,470 Medicare Advantage beneficiaries in an integrated HMO during 2006 and 2007. We used descriptive analyses to characterize three sub-populations (those who reach the DBT in 2006 only, in 2006 and 2007, or neither year) in terms of demographics, morbidity, generic and brand name medication use, utilization, diagnoses, procedures, use of catastrophic benefits, and smoking status.
Results: 859 members reached the DBT in both 2006 and 2007 (repeaters), 904 in 2006 only, and 25,707 in neither year. Relative to those who reached the DBT in neither year, repeaters had significantly higher morbidity; as reflected by significant differences between groups in all descriptive categories. However, only a subset of these characteristics significantly differentiated between repeaters and those who reached the DBT in 2006 only: repeaters had higher rates of outpatient utilization (primary care, specialty care, and emergency department); were more likely to have a history of tobacco use, diagnoses of COPD, history of stroke, long-term anticoagulation, and dementia; and had greater use of specific trade name medications, particularly those used to treat respiratory symptoms. Repeaters and those who reached the DBT in 2006 only did not differ in socioeconomic status, use of specific generic medications (except prednisone), reaching catastrophic coverage, or multiple chronic diagnoses and procedures.
Conclusions: In this initial exploration, Medicare Advantage beneficiaries who repeatedly reached the DBT differ from those who only reached it in one year in utilization, selected diagnoses, and use of certain trade-name medications. Several of these brand medications are for pulmonary conditions in individuals with a history of smoking—a finding that deserves additional investigation.
