Health Care System-level Factors Associated With Performance on Medicare STAR Adherence Metrics in a Large, Integrated Delivery System

Abstract

Background:The Centers for Medicare and Medicaid Services provide significant incentives to health plans that score well on Medicare STAR metrics for cardiovascular disease risk factor medication adherence. Information on modifiable health system-level predictors of adherence can help clinicians and health plans develop strategies for improving Medicare STAR scores, and potentially improve cardiovascular disease outcomes.Objective:To examine the association of Medicare STAR adherence metrics with system-level factors.Research Design:A cross-sectional study.Subjects:A total of 129,040 diabetes patients aged 65 years and above in 2010 from 3 Kaiser Permanente regions.Measures:Adherence to antihypertensive, antihyperlipidemic, and oral antihyperglycemic medications in 2010, defined by Medicare STAR as the proportion of days covered ≥80%.Results:After controlling for individual-level factors, the strongest predictor of achieving STAR-defined medication adherence was a mean prescribed medication days’ supply of >90 days (RR=1.61 for antihypertensives, oral antihyperglycemics, and statins; all P<0.001). Using mail order pharmacy to fill medications >50% of the time was independently associated with better adherence with these medications (RR=1.07, 1.06, 1.07; P<0.001); mail order use had an increased positive association among black and Hispanic patients. Medication copayments ≤$10 for 30 days’ supply (RR=1.02, 1.02, 1.02; P<0.01) and annual individual out-of-pocket maximums ≤$2000 (RR=1.02, 1.01, 1.02; P<0.01) were also significantly associated with higher adherence for all 3 therapeutic groupings.Conclusions:Greater medication days’ supply and mail order pharmacy use, and lower copayments and out-of-pocket maximums, are associated with better Medicare STAR adherence. Initiatives to improve adherence should focus on modifiable health system-level barriers to obtaining evidence-based medications.

Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling

“…38,40,47 The remaining four studies considered (1) 30 days' versus 60 days' supply, 39 (2) 100 days' versus 34 days' supply, 44 (3) 90 days versus < 90 days' supply 37 and (4) prescription lengths of ≤ 90 days. 43 The number of medications examined in a single study ranged from one 40 to 'any medication for a chronic condition'.…”

“…35,37,[39][40][41]44,48,49 Ryvkin et al 38 did not report the length of their study. The most common outcomes measured were adherence, 35,36,39,40,[43][44][45]47 wastage 32,36,38,41,42,45,46,48 and costs. 42,[44][45][46]49 When the study design was not reported 35,36,38,43,46 or was unclear, 41,49 the design was classified by three reviewers (JE, SK and CMiani) based on the information presented, and guided by the NICE algorithm for classifying quantitative study designs.…”

“…43 The number of medications examined in a single study ranged from one 40 to 'any medication for a chronic condition'. 49 The most common clinical classes evaluated were lipid-lowering agents, The study periods ranged from 3 months 46 to 7 years; 37 only one study was conducted over a period of less than 1 year, 46 six studies were conducted over a 12-month period 32,36,42,43,45,47 and eight studies were conducted over a period of more than 1 year. 35,37,[39][40][41]44,48,49 Ryvkin et al 38 did not report the length of their study.…”

“…42 Half of the studies specified the insurance scheme that patients were enrolled in: two (US) studies included predominantly indigent populations (adults who do not have health insurance and are not eligible for Medicaid, Medicare or private health insurance), 39,43 two studies were conducted among Medicaid patients, 44,45 four studies were set in Veterans Health Administrations 37,40,42,46 and one study used data from Kaiser Permanente health-care delivery sites. 47 All of the studies were conducted in the USA. In the majority of studies, there was insufficient information presented to determine whether or not patients were being treated exclusively in primary care settings.…”

“…In the vast majority of the studies, the authors undertook a secondary data analysis of pharmacy claims data. 32,[36][37][38][40][41][42][43][44][45][46][47]49 For five of the included studies, only an abstract was available, 35,36,38,41,48 and a sixth included article was an extended conference abstract. 46 Although we attempted to contact the authors of these reports, the full papers corresponding to these abstracts could not be obtained.…”