Disparity Implications of the Eligibility Criteria for Medication Therapy

Management Services among the Non-Medicare Population

Junling Wang, Ph.D.,Lawrence M. Brown, Pharm.D., Ph.D.

Song Hee Hong, Ph.D.Associate Professors

Division of Health Outcomes and Policy Research

The University of Tennessee College of Pharmacy

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Presenter Disclosures

(1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

Junling Wang, Ph.D.

No relationships to disclose.

BackgroundMedicare Prescription Drug Improvement

and Modernization Act (Medicare Modernization Act or MMA) took effect in 2006.[1]

Medication therapy management (MTM) services to be provided as part of the prescription drug (Part D) benefits as required by the Centers for Medicare and Medicaid Services (CMS).

Three eligibility criteria for MTM services:◦Have multiple chronic conditions◦Use multiple covered drugs◦Be likely to incur over $4,000 in drug

costs

1. Centers for Medicare & Medicaid Services. Department of Health and Human Services. Medicare Program; Medicare prescription drug benefit. Final rule. Fed Regist. 2005;70:4193-585. 3

BackgroundMTM is a “distinct service or group

of services that optimize therapeutic outcomes for individual patients.”

Provided by licensed pharmacists or other qualified health care providers.

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BackgroundBeneficial for patients with chronic

conditions such as hypertension, and diabetes.

Prevalence of these diseases is higher in minority populations than in Whites, including the prevalence of poor control.

Thus, MTM could be an important tool for reducing outcome disparities.

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BackgroundHealth insurance plans other

than Medicare Part D plans have also implemented MTM programs.

Some have included similar components of the Part D MTM eligibility criteria,[2,3] since Medicare is the nation’s leading purchaser and regulator of health care.2. Schommer JC, et al. Pharmacist-provided medication therapy management (part 2): payer

perspective in 2007. J Am Pharm Assoc. 2008;48:478-86.

3. Wisconsin Pharmacy Quality Collaborative. 2011. Wisconsin Pharmacy Quality Collaborative Medication Therapy Management Services Program. Accessed at: http: //ww.pswi.org/professional/WPQC%20Program%20Description.pdf, October 25, 2011.

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BackgroundHistorically, racial and ethnic

minorities have been found to use fewer prescription drugs and incur lower drug costs than do Whites.

Our recently published analyses of historical data before Part D implementation demonstrated that among the Medicare population, racial and ethnic minorities are less likely to be eligible for MTM services than are Whites (non-Hispanic Blacks, 21-34% lower; Hispanics, 32-38% lower).[4]

4. Wang J, et al. Disparity implications of Medicare eligibility criteria for medication therapy management services. Health Serv Res. 2010;45:1061-82.

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Study ObjectivesTo examine whether there are

racial and ethnic disparities in the likelihood of meeting MTM eligibility criteria among non-Medicare beneficiaries,◦According to 2008 eligibility criteria.

◦According to 2010-2011 eligibility criteria

◦Among individuals with hypertension, heart disease and diabetes.

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MethodsMedical Expenditure Panel Survey

(2007-2008).◦A federal survey carried out by the

Agency for Healthcare Research and Quality.

◦With the purpose of providing information on national health services utilization and expenditures from a national representative sample of non-institutionalized civilians.

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MethodsMTM eligibility criteria were designed

to be flexible and to evolve.May examine lower limit, median,

mode, and upper limit values for the eligibility criteria.

For 2008, for the limits based on◦The number of covered prescriptions - 2,

5, 5,15.◦The number of chronic conditions - 2, 3, 3,

5.◦Part D drug costs ≥$4,000 (constant).

Nine possible threshold combinations◦Median values for main analysis.◦All other combinations in sensitivity

analyses.

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MethodsFor 2010-2011 criteria

◦Allowable minimum number of covered prescriptions was lowered to 8 (2, 5, 8, 8).

◦Allowable minimum number of chronic conditions was lowered to 3 (2, 3, 3, 3).

◦Part D drug costs ≥$3,000 (constant).

◦Six possible combinations One in main analysis, five in sensitivity

analyses. 11

MethodsSurvey-weighted chi-square test

◦Compared the proportions of individuals meeting MTM eligibility criteria across racial and ethnic groups.

Survey weighted logistic regression◦Adjusted for confounding factors.◦Predisposing, enabling, and need factors

in Anderson’s Behavioral Model of Health Services Utilization. Age, gender, marital status, poverty

categories, highest degree received, health insurance, geographic regions, metropolitan statistical area, and self-perceived health status.

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Results

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Whites Blacks Hispanics

No. % No. % No. %

Age: 18-30 4,202 26.70 1,911 33.22 3,261 36.89 31-40 3,383 19.67 1,254 21.49 2,407 25.86 41-50 3,973 23.16 1,330 21.98 1,985 20.86 >50 5,133 30.47 1,428 23.30 1,589 16.39

Income: Poor 1,605 7.30 1,424 19.28 2,072 18.01

Near Poor 533 2.40 351 4.72 780 6.69 Low Income 1,745 9.28 1,120 15.47 2,166 20.13

Middle Income 5,162 30.51 1,831 33.77 2,826 33.33 High Income 7,646 50.51 1,197 26.77 1,398 21.84

Table 1. Socio-demographic characteristics across racial and ethnic groups.

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Table 1. Socio-demographic characteristics across racial and ethnic groups (continued)

Whites Blacks HispanicsNo. % No. % No. %

Education: < High School 2,502 13.30 1,562 22.76 4,660 43.51

High School 7,624 45.37 2,999 51.45 3,307 39.22 College Degree 3,279 21.03 598 12.16 607 8.99 > College Degree 1,644 10.60 259 5.47 184 2.90 Other 1,581 9.69 456 8.16 410 5.37

Self-perceived health status: Excellent 4,834 30.17 1,475 26.94 2,106 25.51 Very Good 5,853 35.77 1,827 32.14 2,754 30.90

Good 4,326 25.02 1,840 29.57 3,074 31.59 Fair 1,267 7.01 607 9.05 1,102 10.03 Poor 390 2.02 155 2.31 197 1.97

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Analyses No. of Drugs No. of Conditions

Groups No. Eligible % Eligible

Main >=5 >=2 Whites 677 3.73Blacks 159 2.57Hispanics 149 1.53

Sensi. 1 >=5 >=3 Whites 600 3.27Blacks 142 2.31Hispanics 130 1.32

Sensi. 2 >=5 >=5 Whites 370 1.93Blacks 78 1.20Hispanics 78 0.69

Sensi. 3 >=2 >=3 Whites 633 3.46Blacks 153 2.43Hispanics 134 1.37

Sensi. 4 >=2 >=2 Whites 734 4.09Blacks 178 2.82Hispanics 162 1.71

Table 2. Number and percentage eligible for MTM services according to the main analysis and various sensitivity analyses

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Coefficient Estimate

P Odds Ratio

Lower Limit of the CI for

OR

Upper Limit of the CI for

ORUnadjusted Model

Blacks -0.38 0.0015 0.68 0.54 0.86

Hispanics -0.91 <.0001 0.40 0.31 0.52

Adjusted Model

Blacks -0.51 0.0003 0.60 0.45 0.79

Hispanics -0.62 <.0001 0.54 0.40 0.72

Table 3. Racial and ethnic disparities in the likelihood of meeting MTM eligibility criteria according to logistic regression for the main analysis for 2008 criteria (reference group: whites)

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Figure 1. Odds ratios for meeting the 2008 MTM eligibility criteria.

Main 2008 Sensi. 1 Sensi. 2 Sensi. 3 Sensi. 4 Sensi. 5 Sensi. 6 Sensi. 7 Sensi. 80.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.60 0.61

0.48

0.60 0.60

0.48

0.66 0.66

0.530.54 0.53

0.41

0.50

0.54

0.41

0.34 0.330.31

Blacks

Hispanics

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Figure 2. Odds ratios for meeting the 2008 MTM eligibility criteria in the subpopulation with the three chronic conditions.

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Main 2008 Sensi. 1 Sensi. 2 Sensi. 3 Sensi. 4 Sensi. 5 Sensi. 6 Sensi. 7 Sensi. 80.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.47

0.44

0.31

0.44

0.47

0.310.28 0.29 0.29

0.500.48

0.41

0.50

0.59

0.49

0.35 0.360.34

Blacks

Hispanics

Discussions and ConclusionsBlacks and Hispanics are less likely

than Whites to be eligible for MTM eligibility criteria among the non-Medicare population.

Medicare eligibility criteria have disparity implications among the non-Medicare population.

Due to the catalyst role for Medicare, the eligibility criteria for MTM services need to be changed first for Medicare.

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Discussions and ConclusionsMTM eligibility criteria is a value-

based strategy because those eligible have more complex medical conditions and have greater potential to benefit from MTM services.

However, value-based strategy are oftentimes in conflict with equity doctrine.

Policy makers need to be careful when setting value-based strategies.

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Discussions and ConclusionsFuture research should examine the

health implications of the disparities in meeting MTM eligibility criteria.

Future research should also examine strategies of eliminating disparities in meeting MTM eligibility criteria.

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AcknowledgementsResearch assistance: Songmei Meng,

M.S., and Kiraat D. Munshi, M.S.Funding: This study was funded by the

Pharmaceutical Research and Manufacturers of America Foundation Health Outcomes Research Starter Grant.

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Contact Information:

Junling Wang, Ph.D.Division of Health Outcomes and Policy

Research, University of Tennessee College of Pharmacy

Email: jwang26@uthsc.eduPhone: 901-448-3601

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