Fragmentation of Medication Management in Medicare

描述（由申请人提供）：医疗保险中的多重疾病越来越普遍，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）受益人比例稳定在67%，但患有4种以上慢性病的受益人数量从24%显著增加到36%。67%患有两种或两种以上慢性病的受益人在2008-2011年期间承担了不成比例的FFS支出份额，原因是住院和门诊使用率较高。由于多重疾病的高流行率和不成比例的成本，为世纪挑战挑战受益人确定有效的可持续护理模式是政策制定者和从业者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难以实现，因为在医疗保险示范方面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著改善。在这些先前的努力中，护理的一个方面受到了很少的关注，即药物管理连续性（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年每位医疗保险受益人平均要看2名初级保健医生和5名专科医生，而且提供者的数量随着病情的增加而增加。因此，由多个提供者提供的不协调护理可能是一种机制，通过这种机制，多种疾病导致患有多种慢性病（MCC）的受益人产生不利的健康和经济后果。多个提供者增加了多个开处方者和分散药物管理的可能性。反过来，这可能导致治疗遗漏、多药、危险或重复处方以及药物不良事件，特别是对MCC受益人而言。MCCs药物的最佳协调需要持续监测、调整和重新评估护理目标，这在患者和提供者之间持续的纵向合作关系中是最有效的。通过减少开处方者的数量来改善药物管理的连续性（COMM），使之接近一个“药物之家”，这可能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。有关于药物和解的研究，应发生当患者过渡到门诊护理出院后。然而，关于……的信息却少得惊人

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.