Report: Medication Use among Medicare Patients Extremely Unbalanced
By Mia Burns (firstname.lastname@example.org)
In a new report from the Dartmouth Atlas Project, researchers took their first look at prescription drug use. The data shows that use of both effective and risky drug therapies by Medicare patients varies widely across U.S. regions. This offers further evidence that location is a key determinant in the quality and cost of the medical care that patients receive, according to the researchers.
Dartmouth researchers also found that the health status of a region’s Medicare population accounts for less than a third of the variation in total prescription drug use, and that higher spending is not related to higher use of proven drug therapies. The study raises questions about whether regional practice culture explains differences in the quality and quantity of prescription drug use.
“Prescription drugs represent a growing portion of the healthcare we provide to patients,” says Jeffrey C. Munson, M.D., M.S.C.E., lead author and assistant professor at The Dartmouth Institute for Health Policy & Clinical Practice. “Many drugs we prescribe are effective at reducing the burden of disease and improving quality of life for our patients. Other drugs are less effective, and some may even be harmful. It is important that we find the right balance between providing the care that patients need while avoiding the care they neither need nor want. This study is our first look at prescription drug use and helps us understand how well physicians are achieving this balance.”
The report offers an in-depth look at how prescription drugs are used by Medicare beneficiaries in the program’s Part D drug benefit, which had 37 million enrollees in 2012. The report separates the country into 306 regional health care markets and examines variations among them in the quantity and quality of prescription drug use, spending, and use of brand name drugs. As a way to examine the quality of care, the report looks at prescription use in three categories: drug therapies proven to be effective for patients who have suffered heart attacks, have diabetes, or have broken a bone; discretionary medications, which have less clear benefits, but may be effective for some patients who take them; and potentially harmful medications, for which risks generally outweigh benefits. “Our primary objective was to describe physician behavior to other physicians and the public in a way that will improve the care of our patients,” Dr. Munson told Med Ad News Daily.
For twenty years the Dartmouth Atlas has demonstrated wide regional variation in health services utilization that cannot be explained by patient needs or preferences alone, according to the report. The variation largely reflects regional differences in the use of medical services of uncertain benefit, rather than differences in the use of effective care. As outlined in previous Atlas publications, local healthcare capacity and practice style appear to drive much of this observed variation. The extent to which prescription drug use varies and mirrors the utilization patterns of non-prescription services is not known, but it warrants exploration as the use of prescription medications gains an increasingly important role in healthcare.
Regarding the implications for medical educators, Dartmouth researchers state in the report that specific skills must be taught to medical trainees and practicing physicians. Prescribers should be able to engage effectively in the process of shared decision-making around prescription drug therapy. Finally, the next generation of physicians will need a more sophisticated understanding of health policy and insurance coverage. Prescribing decisions have important financial ramifications for patients, and these are often poorly or incompletely understood by clinicians. Dr. Munson told Med Ad News Daily, “This has to start from the very beginning with improved education during each step of medical training. Medical schools are beginning to incorporate topics related to health policy and insurance coverage, but we have a long way to go. We also need to incorporate the subject more completely in our continuing medical education of current physicians and trainees. Policies regarding healthcare and insurance coverage have real implications for our patients and our practice, and we need to understand these more clearly if we are going to advocate effectively for changes that improve the care we deliver.”
The average Medicare Part D patient filled 49 standardized 30-day prescriptions in 2010, the researchers say. At the high end, patients in Miami filled an average of 63 prescriptions, compared to patients in Grand Junction, Colo., who filled 39 prescriptions per year. Other high-use regions included Lexington, Ky., with 59 prescriptions, and Huntington, W.Va., with 58, compared to low-use regions in Albuquerque, N.M., checking in with 40 prescriptions, and San Mateo County, Calif. with 41.
“This report demonstrates how far we still have to go as a nation to make sure people get the care they need when they need it,” said Katherine Hempstead, Ph.D., M.A., senior program officer at the Robert Wood Johnson Foundation, a longtime funder of the Dartmouth Atlas Project. “Instead of varying widely, patterns of care should be nearly uniform across the country for non-controversial drug therapies with a strong evidence for their use.”
Spending on prescriptions by the Part D drug plans and their patients totaled $2,670 per beneficiary. In addition, spending varied nearly threefold across regions, with a $2,968 difference between the lowest-spending region—St. Cloud, Minn. at $1,770—and the highest spending region, Miami at $4,738.
“We need to learn from regions that consistently provide high-quality care, and focus attention on regions that appear to offer the worst of both worlds: high-risk and discretionary medications and, in relative terms, low use of effective drug therapies,” said Nancy Morden, M.D., M.P.H., report co-author and associate professor at The Dartmouth Institute for Health Policy & Clinical Practice. “This will help us understand and ultimately improve prescribing quality for all Medicare beneficiaries.”
Posted: October 2013