Boston—Older adults in traditional fee-for-service Medicare Part D plans appear to have higher usage of high-risk medications (HRMs) compared with those enrolled in Medicare Advantage plans, according to a recent study.

An article in the Journal of the American Medical Association Network Open advised about “concerning disparities” in female, American Indian or Alaska Native, and white populations, which had the highest use of HRMs compared with others.

The cohort study of nearly 14 million matched pairs of beneficiary-years also found that the difference in rates between the two insurance types narrowed between 2013 and 2018.

Researchers from Harvard T.H. Chan School of Public Health and colleagues pointed out, “Limiting the use of high-risk medications (HRMs) among older adults is a national priority to provide a high quality of care for older beneficiaries of both Medicare Advantage and traditional fee-for-service Medicare Part D plans.”

The cohort study used a 20% sample of Medicare Part D data on drug prescriptions filled from 2013 to 2017 and a 40% sample from 2018. Included were Medicare beneficiaries aged 66 years or older who were enrolled in Medicare Advantage or traditional Medicare Part D plans, with data analyzed between April 1, 2022, and April 15, 2023.

The primary outcome was defined as the number of unique HRMs prescribed to older Medicare beneficiaries per 1,000 beneficiaries. For the study, the investigators propensity score–matched, on a year-to-year basis, about 5.6 million unique Medicare Advantage beneficiaries to about 6.6 million unique traditional Medicare beneficiaries between 2013 and 2018. The cohorts were similar in age, with a mean of about 75.6; both cohorts were about 59% males and slightly more than 77% non-Hispanic white.

“On average in 2013, Medicare Advantage beneficiaries filled 135.1 (95% CI, 128.4-142.6) unique HRMs per 1,000 beneficiaries compared with 165.6 (95% CI, 158.1-172.3) HRMs per 1,000 beneficiaries for traditional Medicare,” the authors reported. “In 2018, the rate of HRMs had decreased to 41.5 (95% CI, 38.2-44.2) HRMs per 1,000 beneficiaries in Medicare Advantage and to 56.9 (95% CI, 54.1-60.1) HRMs per 1,000 beneficiaries in traditional Medicare.”

They added that during the study period, “Medicare Advantage beneficiaries received 24.3 (95% CI, 20.2-28.3) fewer HRMs per 1,000 beneficiaries per year compared with traditional Medicare beneficiaries. Female, American Indian or Alaska Native, and white populations were more likely to receive HRMs than other groups.”

The study defined high-risk medications (HRMs) as medications “that should be avoided for older patients because of age-related changes in pharmacodynamics and chronic illness burden that may increase these patients’ risk of avoidable hospitalization, health care spending, and death,” pointing out that they are commonly prescribed to older adults, despite a consensus that they should be minimized.

“As people live longer and multimorbidity continues to rise, the risk of potentially harmful drug-disease interactions and adverse events will also likely increase,” according to the researchers. “Therefore, identification of strategies that reduce the use of HRMs in this population is critically important.”

As to why Medicare Advantage patients have lower HRM usage, the authors posited, “There are reasons to believe that Medicare Advantage plans might have better management of HRM rates given their more aggressive utilization management strategies, whereby they contract with clinicians who generally perform better on quality measures. Additionally, given that Medicare Advantage plans are at risk for total costs of care, including costs of complications associated with HRM use, they may have more incentive to minimize HRMs.”

They also noted that recent efforts, such as the Merit-based Incentive Payment System to incentive better care in traditional Medicare programs, might be changing prescription patterns.

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