Prescription drugs accounted for 11% of Medicare spending in 2010, but are expected to account for 20% of this budget by 2020. The purpose of this subproject is to advance our understanding of the use and efficiency of prescription drugs among Medicare beneficiaries. First, we characterize the use of pharmaceutical drugs in the U.S. Medicare population at the level of the region or physician-hospital network (PHN) into four categories depending on efficiency or effectiveness - that is, value per dollar spent. These range from the first category, highly effective, to the fourth category, drugs which could lead to adverse effects on health. In this and subsequent analyses, we will consider factors that may affect the efficiency of pharmaceutical use, such as care fragmentation, academic affiliation, health information technology adoption, market structure, and for some physicians, board scores from the American Board of Internal Medicine examinations. These measures can also be used across other subproject analyses, for example for PHNs in subproject 1 and regions in subproject 4. Second, we focus on pharmaceutical treatments for specific cohorts: myocardial infarction survivors, hip fracture survivors, and incident cases of chronic pulmonary disease. This focus allows us to adjust more easily for patient level factors and identify clearly effective treatments (e.g., clopidogrel following a drug-eluting stent). In later years, data will permit assessment of the impact of payment structure such as shared savings and partial capitation on prescription use measures. Third, we use the cohorts developed in the previous subsection to measure substitution effects, the extent to which spending wisely on highly effective pharmaceuticals may have positive effects on downstream healthcare costs, and conversely for those drugs with little known value (or even negative value). To adjust for differences across areas in underlying risk, we will draw on Project 5's risk adjustment measures. Finally, we describe differences in prescription drug use in population subgroups. Early work shows substantial differences in use of some effective medications among Medicare subgroups (e.g. Black, older, poor) compared to the population overall. In addition, we intend to study the under-65 Medicare population (largely those receiving Social Security Disability Insurance) where pharmaceutical treatment for mental illness is likely to be common.

Public Health Relevance

This subproject seeks to understand how variations across physician-hospital networks (PHNs) affect the health, quality of care, and health costs of the Medicare population. These findings could have first-order implications for measuring and improving pharmaceutical care across PHNs, as well as providing a better understanding of how drugs are used in actual clinical practice for, say, younger patients with mental illness or the very old, rather than those patients typically selected for randomized trials.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Research Program Projects (P01)
Project #
Application #
Study Section
Special Emphasis Panel (ZAG1-ZIJ-1 (01))
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Dartmouth College
United States
Zip Code
Goodney, Philip P; Tarulli, Massimo; Faerber, Adrienne E et al. (2015) Fifteen-year trends in lower limb amputation, revascularization, and preventive measures among medicare patients. JAMA Surg 150:84-6
Colla, Carrie H; Sequist, Thomas D; Rosenthal, Meredith B et al. (2015) Use of non-indicated cardiac testing in low-risk patients: Choosing Wisely. BMJ Qual Saf 24:149-53
Morden, N E; Schpero, W L; Zaha, R et al. (2014) Overuse of short-interval bone densitometry: assessing rates of low-value care. Osteoporos Int 25:2307-11
Mangalmurti, Sandeep; Seabury, Seth A; Chandra, Amitabh et al. (2014) Medical professional liability risk among US cardiologists. Am Heart J 167:690-6
Chen, Christopher; Scheffler, Gabriel; Chandra, Amitabh (2014) Readmission penalties and health insurance expansions: a dispatch from Massachusetts. J Hosp Med 9:681-7
Schoenfeld, Andrew J; Harris, Mitchel B; Liu, Haiyin et al. (2014) Variations in Medicare payments for episodes of spine surgery. Spine J 14:2793-8
Reames, Bradley N; Shubeck, Sarah P; Birkmeyer, John D (2014) Strategies for reducing regional variation in the use of surgery: a systematic review. Ann Surg 259:616-27
Sirovich, Brenda E; Lipner, Rebecca S; Johnston, Mary et al. (2014) The association between residency training and internists' ability to practice conservatively. JAMA Intern Med 174:1640-8
Lewis, Valerie A; Colla, Carrie H; Schoenherr, Karen E et al. (2014) Innovation in the safety net: integrating community health centers through accountable care. J Gen Intern Med 29:1484-90
Liu, Stephen K; Munson, Jeffrey C; Bell, John-Erik et al. (2014) Response letter to Herbert L. Muncie, Jr. J Am Geriatr Soc 62:998-9

Showing the most recent 10 out of 154 publications