October 16, 2013
Health Plans Underreport Percentage of Risky Prescriptions to Medicare Beneficiaries

Providence, RI—The average rate of risky medications prescribed for the elderly is higher than self-reported by Medicare Advantage health plans, according to a new study from Brown University.

For the study, published recently in Annals of Internal Medicine, researchers sampled 172 insurance plans that provided data on that quality measure. They found that the average rate of prescribing at least one of about 100 medicines considered risky in patients older than 65, as reported by the insurance plans, was 5.8% more favorable than the research calculations.

According to the results, the mean rate of high-risk prescribing derived from Part D claims was 26.9% (95% CI, 25.9%-28.0%), compared to the mean plan-reported rate of 21.1% (CI, 20.0%-22.3%). Approximately 95% of plans underreported rates of high-risk prescribing relative to calculated rates derived from Part D claims.

Study authors add that, among 103,680 plan subscribers present in both the sample of Part D claims and the government’s Healthcare Effectiveness Data and Information Set (HEDIS) in 2006, Medicare Advantage plans incorrectly excluded 10.3% as ineligible for the high-risk prescribing measure. The authors assert that, based on their calculations, about 500,000 more seniors received high-risk medications than the health plans reported.

A list of the HEDIS high-risk drugs is available here.

For the study, researchers compared the plans reports to HEDIS for 2006 and 2007 to rates the researchers derived from Medicare Part D drug claims during the same time period—in essence, the health plan’s pharmacy data. A random sample of about 1,000 patients enrolled in each of those plans was used for the calculations.

“We're using the same sources of data that Medicare Advantage plans are supposed to be using to derive this information,” said lead author Alicia Cooper, a former Brown doctoral student who now works for the State of Vermont.

Corresponding author Amal Trivedi, MD, MPH, associate professor of health services policy and practice at the Brown University School of Public Health, noted that 95% of plans erred in their own favor, while only nine of 172 plans came within 1% of the rate the researchers calculated.

“We can't say anything about motive, but the direction is important in that they underreport the use of these medications,” said Trivedi. “Their stated performance is much better than their actual performance.”

“The plans that were the most accurate were the ones that suffered the greatest penalties when using the plan-reported rates,” Trivedi added.

Based on the revised statistics, Medicare Advantage is very similar to Medicare fee-for-service in terms of high-risk prescription rates, the authors write.

U.S. Pharmacist Social Connect