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Medicare Part D Plan Generosity and Medication Use Among Dual-eligible Nursing Home Residents

Huskamp, Haiden A. PhD*; Stevenson, David G. PhD*; O’Malley, A. James PhD; Dusetzina, Stacie B. PhD‡,§,∥; Mitchell, Susan L. MD, MPH¶,#; Zarowitz, Barbara J. PharmD, FCCP, BCPS, CGP, FASCP**; Chernew, Michael E. PhD*; Newhouse, Joseph P. PhD*,††,‡‡

doi: 10.1097/MLR.0b013e31829fafdc
Original Articles

Background: In 2006, dual-eligible nursing home residents were randomly assigned to a Medicare Part D prescription drug plan (PDP). Subsequently, residents not enrolled in qualified plans at the start of the next year were rerandomized. PDPs vary in generosity through differences in medication coverage and utilization management. Therefore, residents’ assigned plans may be relatively more or less generous for their particular drugs. The impact of generosity on residents’ medication use and health outcomes is unknown.

Methods: Using data from 2005 to 2008, we estimated logistic regression models of the impact of coverage and utilization management on the risk for medication changes and gaps in use, hospitalizations, and death among elderly nursing home residents using 1 of 6 selected drug classes, adjusting for patient characteristics.

Results: Few current medication users faced noncoverage of their drug (0.4% to 8.7%) or prior authorization or step therapy requirements if the drug was covered (1.1% to 37.4%). After adjusting for individual-level covariates, residents with noncovered drugs were more likely than residents with covered drugs to change medications in most classes studied (eg, for 2006 angiotensin receptor blocker users, the adjusted average probability of medication change was 0.35 when uncovered vs. 0.11 when covered). Those subjected to prior authorization or step therapy were more likely to change in a subset of classes. There were no statistically significant differences in the rates of hospitalization or death after correcting for multiple comparisons.

Conclusions: The Part D benefit’s special protections for nursing home residents may have ameliorated the health impact of coverage limits on this frail elderly population.

Supplemental Digital Content is available in the text.

*Department of Health Care Policy, Harvard Medical School, Boston, MA

The Dartmouth Institute and Geisel Medical School at Dartmouth, Lebanon, NH

Division of General Medicine and Clinical Epidemiology, School of Medicine

§Department of Health Policy and Management, Gillings School of Global Public Health

Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC

Institute for Aging Research, Hebrew SeniorLife, Deaconess Medical Center

#Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA

**Omnicare Inc., Livonia, MI

††Department of Health Policy and Management, Harvard School of Public Health, Boston

‡‡Harvard Kennedy School, Cambridge, MA

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by the National Institute on Aging (R01 # AG034085). D.G.S. was supported in part by a training grant from the National Institute on Aging (K01 AG038481). S.L.M. is supported by a mid-career award from the National Institute on Aging (K24AG033640). At the time of this work, S.B.D. was funded by the National Institute of Mental Health through Harvard Medical School, Department of Health Care Policy, T32MH019733-17. A.J.O. was also supported by the National Institutes of Mental Health (1RC4MH092717-01).

J.P.N. is the director of and holds equity in Aetna, which sells Part D plans. B.J.Z. is an employee of Omnicare Inc., and holds Omnicare Inc., stock. She participates in research projects funded by grants from Amgen, Sanofi-Aventis, Mylan, AbbVie, Astellas, and Optimer. M.E.C. reports the following potential conflicts: Research support: CareFirst, NIA, The Commonwealth Fund, Charles H. Hood Foundation, InHealth, Institute of Medicine, Pfizer Inc., Robert Wood Johnson Foundation; Board memberships: Commonwealth Fund Commission of High Performance, Congressional Budget Office, Medicare Payment Advisory Commission, Abbott, FairHealth, Health Research & Educational Trust, National Institute of Health Care Management, CMS Technical Advisory Panel, NC Prevention Partner Advisory Council on Evidence-based Incentives and Benefits, and Massachusetts Medical Society; Consultancy: Massachusetts Medical Society, America’s Health Insurance Plans, Abbott, Humana, SEIU, Precision Health Economics, US Chamber of Commerce, and Milliman; LLC Equity: Benefit Based Designs, Value Based Insurance Design Institute, and Value Based Insurance Design Health; Payment for Manuscript Prep/development: Truven Healthcare Analytics, Precision Health Economics, New America Foundation, and London School of Economics; Role as Journal Editor: Health Services Research and American Journal of Managed Care. The remaining authors declare no conflict of interest.

Reprints: Haiden A. Huskamp, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115. E-mail:

© 2013 by Lippincott Williams & Wilkins.