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.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Research Program Projects (P01)
Project #
5P01AG019783-12
Application #
8588859
Study Section
Special Emphasis Panel (ZAG1-ZIJ-1)
Project Start
Project End
Budget Start
2013-12-01
Budget End
2014-11-30
Support Year
12
Fiscal Year
2014
Total Cost
$162,149
Indirect Cost
$62,056
Name
Dartmouth College
Department
Type
DUNS #
041027822
City
Hanover
State
NH
Country
United States
Zip Code
03755
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Bekelis, Kimon; Missios, Symeon; Coy, Shannon et al. (2018) Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis. World Neurosurg 110:e689-e698
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Moen, Erika L; Bynum, Julie P; Austin, Andrea M et al. (2018) Assessing Variation in Implantable Cardioverter Defibrillator Therapy Guideline Adherence With Physician and Hospital Patient-sharing Networks. Med Care 56:350-357
Bekelis, Kimon; Missios, Symeon; MacKenzie, Todd A (2018) Outcomes of Elective Cerebral Aneurysm Treatment Performed by Attending Neurosurgeons after Night Work. Neurosurgery 82:329-334
Jeffery, Molly Moore; Hooten, W Michael; Henk, Henry J et al. (2018) Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study. BMJ 362:k2833

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