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Characteristics of Medicare Part D Beneficiaries Who Reach the Drug Benefit Threshold in Both of the First Two Years of the Part D Benefit

Bayliss, Elizabeth A. MD, MSPH*†; Ellis, Jennifer L. MSPH*; Delate, Thomas PhD, MS; Steiner, John F. MD, MPH*§¶; Raebel, Marsha A. PharmD*‖

doi: 10.1097/MLR.0b013e3181ca2824
Brief Report

Background: Medicare Part D beneficiaries who reach the drug benefit threshold (DBT) risk adverse health outcomes.

Objectives: We explore clinical characteristics of beneficiaries who repeatedly reach the DBT during the first 2 years of Medicare Part D and may benefit from proactive identification for medication and care management.

Research Design: Retrospective cohort.

Subjects: 25,320 Medicare Advantage beneficiaries of whom 536 reached the DBT in 2006 only, (“2006 only”); 961 reached the DBT in 2006 and 2007 (“both years”); and 23,823 in neither year.

Measures: We assessed repeatedly reaching the DBT (relative to 2006 only) as a function of demographics, morbidity (specific conditions and overall burden), medication use (specific classes and overall burden), utilization, and use of catastrophic and/or additional pharmacy benefits.

Results: Those who reached the DBT in both years had higher morbidity and utilization. In multivariate analyses, they were more likely than the 2006 only group to have one or more of 5 conditions (chronic pulmonary disease, dementia, depression, incontinence, and Parkinson disease), and within these conditions were more likely to use categories of trade-name medications for which there are limited available generic alternatives.

Conclusions: Repeatedly reaching the DBT is a function of the extent and chronicity of disease burden and is characterized by conditions for which there is limited availability of generic medications, and associated common comorbidities. If these findings are confirmed, strategies at practice and policy levels may help such Medicare beneficiaries avoid unnecessary out of pocket expenditures on medications from prematurely reaching the DBT.

From the *Institute for Health Research, Kaiser Permanente, Denver, CO; †Department of Family Medicine, University of Colorado Denver School of Medicine, Denver, CO; ‡Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO; Departments of §Medicine, and ¶Preventive Medicine and Biometrics, University of Colorado Denver School of Medicine, Denver, CO; and ‖School of Pharmacy, University of Colorado Denver, Denver, CO.

Supported, in part, by a grant from the Kaiser Permanente Colorado Institute for Health Research and by the Kaiser Permanente Colorado Pharmacy Department and by the Agency for Healthcare Research and Quality, career development award K08 HS015476 (to E.A.B.).

Poster presented, in part, at the 15th Annual HMO Research Network Conference; April 26–29, 2009, Danville, PA.

Reprints: Elizabeth A. Bayliss, MD, MSPH, Kaiser Permanente, Institute for Health Research, Family Medicine, University of Colorado Denver, PO Box 378066, Denver, CO 80237-8066. E-mail:

© 2010 Lippincott Williams & Wilkins, Inc.