Fragmentation of Medication Management in Medicare

描述（由申请人提供）：医疗保险中的多药疗法越来越普遍，成本也越来越高。1999-2011年，患有2种以上慢性病的医疗保险按服务收费（FFS）受益人的比例稳定在67%，但患有4种以上慢性病的受益人人数从24%显著增加到36%。在2008-2011年期间，67%患有两种或两种以上慢性病的受益人在FFS支出中所占份额不成比例，这是由于住院和门诊使用率较高。由于多重医疗的高流行率和不成比例的费用，为千年挑战委员会受益人确定有效的可持续护理模式是决策者和从业人员的一个关键优先事项。然而，为MCC受益人寻找有效的护理模式仍然是难以捉摸的，因为对医疗保险示范的大量投资并没有在护理质量或医疗保险支出方面取得显着改善。在这些先前的努力中很少受到关注的护理的一个方面是药物管理的连续性（COMM）对患者结果和支出的影响。接受单一提供者的护理与更好的护理体验、更少的急诊室就诊和更少的住院治疗有关。然而，2002年，医疗保险受益人平均有2名初级保健医生和5名专家，提供者的数量随着疾病的增加而增加。因此，由多个提供者提供的不协调的护理可能是一种机制，通过这种机制，多个慢性病患者会对患有多种慢性病的受益人的健康和经济产生不利影响。多个提供者增加了多个处方者和分散的药物管理的可能性。这反过来又可能导致治疗遗漏、多种药物、危险或重复处方以及药物不良事件，特别是对千年挑战委员会受益人而言。MCC药物的最佳协调需要对护理目标进行持续监测、调整和重新评估，这在患者和提供者之间持续的纵向合作伙伴关系中最为有效。通过减少开处方者的数量以接近“药物之家”来改善药物管理的连续性（COMM），可能会转化为更好的疾病控制和更低的支出，特别是对MCC受益人而言。有研究表明，当患者出院后过渡到门诊治疗时，应进行药物协调。然而，令人惊讶的是， COMM在受益人之间的可变性或COMM与对MCC利益相关者重要的结果之间的关联，例如依从性，疾病控制和成本。在之前AHRQ资助的工作中（R21 HS 019445，PI：Macievinski），我们发现开处方者的数量比心脏代谢疾病本身的数量更能预测退伍军人的药物不依从性，急诊室就诊和住院。重要的是要验证这个COMM结构，并评估这些先前的结果是否推广到医疗保险受益人。我们建议利用一种新颖的、丰富的二级数据，将医疗保险索赔与实验室结果联系起来，以评估COMM在MCC受益人中的潜在益处，从而在患有1-3种心脏代谢疾病的医疗保险受益人队列中实现三个目标（糖尿病、高血压和/或血脂异常），这些疾病单独和合并高度流行：1）检查处方人数与糖尿病和血脂异常控制之间的关系。H1：拥有更多处方者的受益人的疾病控制比拥有一名处方者的受益人差。2)检查处方人数与糖尿病、高血压或血脂异常药物依从性之间的关系。H2：拥有更多处方者的受益人的依从性低于拥有一名处方者的受益人。3)检查处方人数和医疗保险支出之间的关联。H3：拥有更多处方者的受益人的支出将高于拥有一名处方者的受益人。这项拟议的研究解决了我们的长期目标，即优化MCC医疗保险受益人的健康和生活质量。本提案响应RFA-HS-14-001的目标，即确定与MCC受益人更好结局相关的患者和系统因素。检查COMM是否与药物不依从性，疾病控制和医疗保险支出相关，可以确定多药治疗导致不良健康和经济后果的机制。如果这是真的，这些发现将表明，MCC结果梯度可以通过改善COMM.com的护理模式来解决。

DESCRIPTION (provided by applicant): Multimorbidity in Medicare is increasingly prevalent and costly. The proportion of Medicare fee-for-service (FFS) beneficiaries with 2+ chronic conditions remained stable at 67% in 1999-2011, but the number of beneficiaries with 4+ chronic conditions increased markedly from 24% to 36%. The 67% of beneficiaries with two or more chronic conditions incurred a disproportionate share of FFS expenditures in both 2008-2011, driven by higher inpatient and outpatient utilization rates. As a result of high prevalence and disproportionate costs of multimorbidity, identifying effective sustainable care models for MCC beneficiaries is a key priority for policymakers and practitioners. However, the search for effective care models for MCC beneficiaries remains elusive because substantial investments in Medicare demonstrations did not achieve significant improvements in care quality or Medicare expenditures. One aspect of care that has received scant attention in these prior efforts is the influence of continuity of medication management (COMM) on patient outcomes and expenditures. Receiving care from a single provider has been associated with better care experiences, fewer emergency room visits and fewer hospitalizations. However, the average Medicare beneficiary saw an average of 2 primary care physicians and 5 specialists in 2002 and the number of providers increased with the number of conditions. Thus, uncoordinated care provided by multiple providers may be a mechanism by which multimorbidity drives adverse health and economic outcomes of beneficiaries with multiple chronic conditions (MCC). Multiple providers increase the likelihood of multiple prescribers and fragmented medication management. This, in turn, can result in therapeutic omissions, polypharmacy, dangerous or duplicative prescriptions and adverse drug events, particularly for MCC beneficiaries. Optimal coordination of medications for MCCs requires ongoing monitoring, adjustment, and re-evaluation of care goals, which is most effective in a continuous longitudinal partnership between patients and providers. Improving Continuity of Medication Management (COMM) by reducing the number of prescribers to approximate a "medication home" may translate into better disease control and lower expenditures, particularly for MCC beneficiaries. There has been research on medication reconciliation that should occur when patients transition to outpatient care after a hospital discharge. However, there is surprisingly little information about variability in COMM across beneficiaries or the association between COMM and outcomes that are important to MCC stakeholders, such as adherence, disease control, and costs. In prior AHRQ-funded work (R21 HS019445, PI: Maciejewski) we found that the number of prescribers was more predictive of medication non-adherence, emergency room visits and hospital admissions by veterans than the number of cardiometabolic conditions themselves. It is important to validate this COMM construct and evaluate whether these prior results generalize to Medicare beneficiaries. We propose to leverage a novel, rich secondary data that links Medicare claims to lab results to evaluate the potential benefits of COMM in MCC beneficiaries to address three aims in a cohort of Medicare beneficiaries with 1-3 cardiometabolic conditions (diabetes, hypertension and/or dyslipidemia) that are highly prevalent individually and in combination: 1) Examine the association between number of prescribers and control of diabetes and dyslipidemia. H1: Beneficiaries with more prescribers will have worse disease control than beneficiaries with one prescriber. 2) Examine the association between number of prescribers and adherence to medications for diabetes, hypertension or dyslipidemia. H2: Beneficiaries with more prescribers will have lower adherence than beneficiaries with one prescriber. 3) Examine the association between number of prescribers and Medicare expenditures. H3: Beneficiaries with more prescribers will have higher expenditures than beneficiaries with one prescriber. The proposed study addresses our long-term objective of optimizing the health and quality of life of Medicare beneficiaries with MCC. This proposal is responsive to RFA-HS-14-001's objective to identify patient and system factors associated with better outcomes for MCC beneficiaries. Examining whether COMM is associated with medication non-adherence, disease control and Medicare expenditures may identify mechanisms by which multimorbidity drives adverse health and economic outcomes. If true, such findings would suggest that the MCC-outcomes gradient can be addressed by models of care that improve COMM.