Helping Veterans Navigate Dual Pharmacy Benefits

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Background: Nearly 30% of Veterans with diabetes dually use Medicare Part D and VA to fill their antidiabetic medications, and dual users have poorer glycemic control and poorer medication adherence than Veterans who fill only through VA. Yet few resources exist to help Veterans understand and navigate between these dual pharmacy benefits. Significance/Impact: The goal of this research is to understand how Veterans are choosing between VA and Part D, identify knowledge gaps, and rigorously develop and test an intervention that will educate and optimize Veteran choice on prescription coverage. Innovation: This research is innovative because it: i) uses a stated-preference research method, called a discrete choice experiment, to quantify Veteran preferences when choosing which pharmacy benefit through which to fill their antidiabetic medications and ii) rigorously develops the first Veteran-facing decision aid that helps improve Veteran decision-making about where to fill their medication. By applying a Veteran-centered intervention focused on access to care and health care value to an aging population with a costly and prevalent condition, this proposal aligns with strategic goals for HSR&D, PBM, and VA in general. Specific Aims: The specific aims of the CDA-2 proposal are: 1) Identify medication acquisition challenges and informational needs that Part D-enrolled Veterans have when filling antidiabetic medications through VA or Medicare Part D; 2) Estimate how Veteran preferences around aspects such as prescription coverage, travel time, wait time, medication copay, and chance of adverse events influence where Part D-enrolled Veterans choose to fill antidiabetic medications; 3) Develop and assess feasibility and acceptability of a decision aid that helps Part D-enrolled Veterans comprehend VA and Medicare Part D prescription benefits to optimize choice on where to fill medications; and 4) Evaluate how dual use of VA and Part D to fill antidiabetic medications affects medication expenditures for Veterans, Medicare, and VA. Methodology: The proposed research consists of four projects, all focused on Part D-enrolled Veterans using antidiabetic medications. Project 1 is a qualitative study to identify knowledge gaps and other medication acquisition barriers that Veterans experience when filling medications through Part D versus VA. Project 1 will comprise of 24 interviews with Part D- enrolled Veterans with type 2 diabetes, and 12 interviews with caregivers. Project 2 consists of a discrete choice experiment study that estimates how Veterans trade off between different aspects such as prescription coverage, travel time, wait time, medication copay, and chance of adverse events when they decide where to fill their medications. Project 3 will involve the development and assessment of feasibility and acceptability of a decision aid based on findings from Aims 1 and 2. Project 4 will encompass a retrospective cohort study, using VA Corporate Data Warehouse medical records linked to Medicare claims data, to study the impact of dual use of pharmacy benefit on costs to Veterans, Medicare, and VA. Implementation/Next Steps: Two IIRs will be submitted to support: i) an expanded secondary data analysis that informs future implementation of the decision aid and ii) a hybrid type I effectiveness-implementation trial assessing the impact of the decision aid on Veteran satisfaction; medication supply, switching, and adherence; glycemic control; and costs to the Veteran and VA.