Racial/ethnic disparities in measure calculations for Part D Star Ratings among Medicare beneficiaries with diabetes,hypertension, and/or hyperlipidemia

BackgroundPrevious literature reported racial/ethnic disparities in the measure assessment of diabetes medication adherence in the Medicare Part D Star Ratings program.ObjectiveThis study examined the likelihood of inclusion in measure calculation across racial/ethnic groups for adherence metrics in Part D Star Ratings among individuals with diabetes, hypertension, and/or hyperlipidemia.MethodsThis was a retrospective cross sectional analysis of a 10% random sample of 2017 Medicare claims linked to Area Health Resources Files. Inclusion in measure calculation was determined based on inclusion/exclusion criteria in adherence metrics for adherence medications for diabetes, hypertension, and hyperlipidemia in Part D Star Ratings developed by the Pharmacy Quality Alliance. Logistic regression and multinomial logistic regression were used to adjust for patient/community characteristics.ResultsThe study sample size was 2 707 216. Compared to Non-Hispanic White (White) beneficiaries, minorities were more likely to be excluded from measure calculation among individuals with 1 condition. For example, among individuals with hypertension, compared to White individuals, the adjusted odds ratios for exclusion for Black, Hispanic, Asian/Pacific Islander and other individuals were 1.46 (95% confidence interval, or CI = 1.42–1.50), 1.38 (95% CI = 1.33–1.43), 1.28 (95% CI = 1.21–1.35), and 1.08 (95% CI = 1.02–1.15), respectively. Among individuals with more than 1 chronic condition, minorities were more likely to be included in fewer calculations for medication adherence measures. For example, among individuals with all 3 conditions, the adjusted relative risk ratios for Black, compared to White, beneficiaries for being included in 0, 1, and 2 measures, versus all 3 measures, were 2.14 (95% CI = 1.99–2.30), 1.49 (95% CI = 1.41–1.56), 1.20 (95% CI = 1.18–1.23), respectively.ConclusionsCompared to White beneficiaries, racial/ethnic minorities are more likely to be excluded from the calculation for adherence measures among individuals with diabetes, hypertension, and/or hyperlipidemia. Future studies should examine whether such disparities exacerbate existing racial/ethnic disparities in health outcomes and devise solutions for these disparities.     

Historical trend of disparity implications of Medicare MTM eligibility criteria

BackgroundNon-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.ObjectivesTo determine whether MTM eligibility criteria would perform differently over time, this study examined the trend of MTM disparities from 1996–1997 to 2007–2008.MethodsThe 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.ResultsThis 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.ConclusionsRacial and ethnic disparities in meeting MTM eligibility criteria may not decrease over time unless MTM eligibility criteria are changed.     

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

BackgroundPrevious 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.ObjectivesTo 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.MethodsThis 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.ResultsBased 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.ConclusionsDisparities 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 racial and ethnic disparities in meeting Medicare medication therapy management eligibility in non-Medicare population

BackgroundPrior 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.ObjectivesTo examine trends in MTM eligibility disparities among the non-Medicare population from 1996–1997 to 2009–2010.MethodsThis 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.ResultsAccording 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]).ConclusionsRacial 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.     

The impact of racial and ethnic disparities in inhaled corticosteroid adherence on healthcare expenditures in adults with asthma

Purpose: The purpose of this study is to determine racial and ethnic disparities with the adherence to inhaled corticosteroids (ICSs) in adults with persistent asthma, and their association with healthcare expenditures.

Methods: A retrospective, cross-sectional study using the Medical Expenditure Panel Survey (MEPS) 2013–2014 data included patients ≥18 years with persistent asthma. Median medication possession ratio (MPR) was used to dichotomize adherence levels. Multivariate regression analysis was conducted to ascertain the association between adherence and race/ethnicity. Total expenditures and association with adherence were analyzed using a generalized linear model with a log link function and gamma distribution. Unadjusted expenditures were compared after bootstrapping.

Results: The average MPR of ICSs for the sample of 277 patients was 0.34. The average MPR level was 0.33 among whites, 0.37 among African-Americans and 0.35 among other minorities. The average MPR was 0.30 among Hispanics, and 0.35 among non-Hispanics. African-Americans were less likely to be adherent than whites (OR 0.95). Hispanics were less likely to be adherent (OR 0.4; CI 0.206–0.777). Higher adherence was associated with significantly higher total health expenditure than lower adherence ($19,223 vs. $12,840 respectively, p?<?.0001). African-Americans had slightly higher total expenditure compared to whites; however, other minorities had significantly lower health expenditures compared to whites (p?=?.01). Non-Hispanics spent significantly less on healthcare compared to Hispanics (p?=?.04).

Conclusions: Valuable insight into the economic cost of the disparities as they relate to persistent asthma provides further evidence of possible ethnic inequities that warrant addressing.     

Economic,clinical, and humanistic outcomes (ECHOs) of pharmaceutical care services for minority patients: A literature review

BackgroundThe U.S. population of racial/ethnic minorities continues to increase; however, health disparities and poor health outcomes among many of them continue to be a major public health problem confronting the U.S. health care system.ObjectivesThe objective of this review was to summarize published pharmaceutical care services literature reporting economic, clinical, and/or humanistic outcomes (ECHOs) among racial/ethnic minorities. Studies that reported differences by race/ethnicity and studies where most participants were from multiracial/ethnic minorities were included.MethodsPubMed and International Pharmaceutical Abstracts databases were searched for articles that reported the effects of pharmaceutical care on ECHOs among racial/ethnic minorities published between January 1980 and November 2010. The literature review was focused on racial groups that included black/African-American, Native American, Indian American Asian, Alaska Native, Native Hawaiian, and Pacific Islander patients, and ethnic group that was non-white Hispanic/Latino patients.ResultsThere were 24 articles that studied the impact of pharmaceutical care on ECHOs by race/ethnicity or where most participants were from multiracial/ethnic minorities. Twenty-three studies reported that pharmaceutical care has a positive impact on health outcomes of the studied populations. About half of the studies meeting inclusion criteria evaluated only 1 type of patient outcome, primarily clinical outcomes. Education/consultation and medication/therapy management were the most commonly evaluated types of pharmaceutical care services throughout the studied groups. Comprehensive disease management was evaluated mainly in multiracial/ethnic populations and blacks/African-Americans. Few studies adopted randomized controlled designs, which make it difficult to attribute changes in patient outcomes to the provision of pharmaceutical care. Nine studies that involved cooperation between pharmacists and other medical professionals reflect an increased tendency for interprofessional collaboration in the current health care system.ConclusionThis review shows that there is a positive relationship between pharmaceutical care and ECHOs in patients from racial/ethnic minority groups. However, more studies are needed to document the effects of pharmaceutical care on reducing racial/ethnic health disparities and to determine which interventions are most effective among certain groups with health disparities.     

The economic implications of the racial and ethnic disparities in the use of selective serotonin reuptake inhibitors*

ABSTRACT

Objectives: Previous studies have examined racial and ethnic disparities in the use of selective serotonin reuptake inhibitors (SSRI). This study aims to examine the economic implications of these disparities.

Research design and methods: In this retrospective observational study, the study sample was adult survey respondents with a diagnosis of depression from the Medical Expenditure Panel Survey (2002–2003). SSRI use was measured as the number of times when SSRIs were obtained. The racial and ethnic disparities in SSRI use were examined employing a negative binomial model. The economic implications of disparities were explored using a linear regression with SSRI use as an independent variable. Interaction terms between the variable for SSRI use and dummy variables for racial and ethnic groups were included to explore whether the relationships between SSRI use and health expenditures differ across racial and ethnic groups.

Results: The mean number of times of SSRI use was higher for non-Hispanic whites than non-Hispanic blacks (3.02 vs. 1.79; p < 0.05) and Hispanic whites (3.02 vs. 1.68; p < 0.05). These differences were still significant after adjusting for covariates (?p < 0.05). In the multivariate analysis, each time of SSRI use was associated with health expenditures of $301 higher. Neither dummy variables for racial and ethnic groups nor the interaction terms between these dummy variables and the variable for SSRI use were significant.

Conclusions: The lower use of SSRIs among minorities compared to non-Hispanic whites is associated with lower health expenditures among minorities. SSRI may be a proxy for improved access to health care due to under-treatment of depression in general. The main limitation of this study is that its observational nature does not allow the researchers to determine whether the association between SSRI use and the increase in health expenditures is a causal effect.     

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

BackgroundSince 2009, pharmacists in all 50 states in the U.S. have been authorized to administer vaccinations.ObjectivesThis 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.MethodsThe 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.ResultsBivariate 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).ConclusionAlthough 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.     

How long does it take to complete outpatient substance use disorder treatment? Disparities among Blacks,Hispanics, and Whites in the US

This research investigates racial and ethnic disparities in outpatient substance use disorder treatment completion and duration in treatment, for different substances, across the US, using the national 2014 Treatment Episode Dataset-Discharge (TEDS-D) data set. Moderated fixed effects logistic regression models assessed effects of race/ethnicity on length of stay in treatment and treatment completion for different substances of use. Moderated models also assessed the differential effect of length of stay on treatment completion among Blacks, Hispanics, and Whites. While Blacks and Hispanics both have significantly lower treatment completion rates than Whites, treatment duration is substantially similar across the three groups. Blacks and Hispanics generally take longer to complete treatment than Whites, though this varies by substance for Hispanics. Disparities in treatment completion persist even after controlling for treatment duration. These results indicate that observed racial and ethnic disparities in treatment completion are not due to differences in length of stay in treatment. Economic, cultural, accessibility, or, potentially, discriminatory, factors may suppress the likelihood of treatment completion for minorities and result in longer treatment durations required for completion. Recognition by treatment providers of the unique challenges to treatment completion faced by minorities may enhance treatment outcomes for minorities in the US.     

The Institute of Medicine report "Unequal Treatment": implications for academic health centers

BACKGROUND: The United States has achieved dramatic improvements in overall health and life expectancy, largely due to initiatives in public health, health promotion and disease prevention. Academic health centers have played a major role in this effort, given their mission of engaging in research, educating health professionals, providing primary and specialty medical services, and caring for the poor and uninsured. However, national data indicate that minority Americans have poorer health outcomes (compared to whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer and HIV/AIDS. Two factors contribute heavily to these racial and ethnic disparities in health: minorities are subjected to adverse social determinants, and they are disproportionately represented among the uninsured. In the last twenty years, however, the literature has highlighted the fact that racial and ethnic disparities occur not only in health, but also in health care. The Institute of Medicine Report, "Unequal Treatment." The Institute of Medicine (IOM) was asked to determine the extent of racial and ethnic disparities in health care. Their report, entitled "Unequal Treatment," found that racial and ethnic disparities in health care do exist, and that many sources, including health care systems, health care providers, patients and utilization managers, are contributors. Recommendations from "Unequal Treatment": Implications for Academic Health Centers. The IOM Report, "Unequal Treatment," provides a series of recommendations to address racial and ethnic disparities in health care, targeted to a broad audience (the executive summary and full IOM Report can be found at www.nap.edu under the search heading "Unequal Treatment"). Several of the recommendations speak directly to the mission and roles of academic health centers, and have clear and direct implications for patient care, education, and research. These recommendations include collecting and reporting health care access and utilization data by patient=s race/ethnicity, encouraging the use of evidence-based guidelines and quality improvement, supporting the use of language interpretation services in the clinical setting, increasing awareness of racial/ethnic disparities in health care, increasing the proportion of underrepresented minorities in the health care workforce, integrating cross-cultural education into the training of all health care professionals, and conducting further research to identify sources of disparities and promising interventions. CONCLUSION: "Unequal Treatment" provides the first detailed, systematic examination of racial/ethnic disparities in health care, and provides a blueprint for how to address them. The report=s recommendations are broad in scope, yet have direct implications for academic health centers.     

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

BackgroundMedicare Part D medication therapy management (MTM) includes an annual comprehensive medication review (CMR) as a strategy to mitigate suboptimal medication use in older adults.ObjectivesTo describe the characteristics of Medicare beneficiaries who were eligible, offered, and received a CMR in 2013 and 2014 and identify potential disparities.MethodsThis 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.ResultsIn 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).ConclusionsCMR 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.     

The use of think-aloud protocols to identify a decision-making process of community pharmacists aimed at improving CMS Star Ratings scores

Background

The Center for Medicare and Medicaid Services (CMS) created the Star Rating system based on multiple measures that indicate the overall quality of health plans. Community pharmacists can impact certain Star Ratings measure scores through medication adherence and patient safety interventions.

Racial difference in diabetes preventive care

BackgroundDiabetes has long been a leading cause of death in the United States, and worldwide. Diabetes-related preventive services are recommended to delay or to avoid diabetes complications. Racial disparity in the receipt of diabetes preventive care is well documented; however, little is known about the contributors to this disparity.ObjectiveThis study aims to explore potential mediators linking race/ethnic disparities to reduced receipt of preventive care, and to better understand the dynamics underlying the relationships between race/ethnic characteristics and preventive care. Implications for pharmacist roles are explored.MethodsThis study used 2008 Medical Expenditure Panel Survey (MEPS) data. The outcome of diabetes preventive care was assessed by participants' self-reports in MEPS. Household income and health insurance coverage were identified as potential mediators based on Andersen's Health Care Utilization Behavior model. Logistic regression was used to examine the direct effects of study independent variables on diabetes preventive care. Path analysis was conducted to identify racial disparities' direct and indirect effects on diabetes preventive care via potential mediators. All estimates were weighted to the U.S. non-institutionalized population.ResultsRacial differences occurred with respect to receiving A1C tests, diabetic foot exams, and eye exams. After controlling for patient age, gender, living area, income, and health insurance status, racial differences persisted in diabetes preventive care. Hispanics were the least likely to receive all three elements of diabetes preventive care. In addition, patients were less likely to receive diabetes preventive care who were younger, lived in rural areas, had lower family income and were uninsured. A lower rate of diabetes preventive care in minority patients was partially explained by their higher rate of being uninsured or having low family income.ConclusionThe results suggest that minority, rural, low-income, uninsured, and young diabetes patients are at a higher risk of not receiving diabetes preventive care. This study is unique in its use of path analysis to assess racial disparities in diabetes preventive care and to do so drawing on Andersen's Health Care Utilization Behavior model. In response to the disparity findings which were reinforced in this study, pharmacists have a need and an opportunity to help identify and address important gaps in diabetes preventive care through diabetes patient assessment, education, referral, and monitoring.     

Medicare star ratings: Stakeholder proceedings on community pharmacy and managed care partnerships in quality: American Pharmacists Association and Academy of Managed Care Pharmacy

ObjectivesTo describe the Medicare star rating system, created by the Centers for Medicare & Medicaid Services (CMS) in 2007; identify quality measures that can potentially be improved through collaboration between health plans and community pharmacy; provide examples of current collaboration between health plans and community pharmacy; and identify collaboration goals, challenges, components, and strategies.Data sourcesNational thought leaders at a conference titled CMS Star Ratings: A Stakeholder Discussion, held on March 21, 2013, supplemented with related information from the literature.SummaryThe Medicare star rating system is part of CMS's efforts to define, measure, and reward quality health care. Approximately one-half of the star rating performance measures can be influenced directly by community pharmacists working in conjunction with payers that must meet the quality measures. In 2012, a weighting system for star ratings was implemented. Of 10 triple-weighted ratings, 8 are related directly and indirectly to medication therapy and thus have the potential to be improved by pharmacist intervention. Plan ratings can have a substantial impact on beneficiary enrollment. Since very small improvements in performance measures can translate into large effects on star ratings, concerted efforts to improve pharmacy-related measures could move a plan to a higher star rating; conversely, inattention to areas such as high-risk medications, antidiabetic pharmacotherapy, and medication adherence could lower a plan's star rating. Topics discussed in this article include the Electronic Quality Improvement Platform for Plans and Pharmacies, or EQUIPP, the payer perspective on pharmacies, programs currently under way in community pharmacies, and ways plans and pharmacies can better collaborate with each other.ConclusionThe pharmacist's ability to work directly with patients to improve medication use is a critical factor in improving health plan Medicare star ratings. Health plans and community pharmacies must forge partnerships based on well-defined goals and innovative tactics to ensure care quality consistent with evolving public and private payment models.