Medicare Part D Plan Generosity & Dual-Eligible Nursing Home Residents

描述（由申请人提供）：医疗保险D部分处方药福利极大地改变了养老院处方药的融资和管理方式，特别是对三分之二的双重医疗保险和医疗补助资格的居民（“双重资格”）。以前，医疗补助计划为双重资格的养老院居民提供药品，现在这些人被随机分配到私人处方药计划（PDP）。pdp在特定药物的处方覆盖范围和使用管理技术方面有所不同。因此，一些符合双重资格的养老院居民被随机分配到对他们目前的药物有慷慨覆盖的pdp，而另一些人则被分配到覆盖范围更有限的pdp。目前还没有实证研究的PDP慷慨对双重资格的养老院居民的健康和福祉的影响。为了评估PDP慷慨对药物使用和居民健康结果的影响，我们建议使用来自大型长期护理药房的药物使用数据，结合最小数据集（MDS）和医疗保险a部分住院索赔2005-2008年期间（D部分实施前一年和实施后三年）的健康结果数据。本应用程序的具体目的是：1)构建针对每个PDP的药物特定措施，其中双重资格的养老院居民被随机分配到；2)检查PDP慷慨对药物改变和停药的影响；3)检查PDP慷慨对健康结果的影响；4)评估药物变化和停药对健康结果的影响。目的2和3利用pdp双重资格的随机化来估计慷慨对药物使用和未受选择偏倚污染的结果的影响。为了确定药物中断是否是PDP慷慨影响健康结果的机制，Aim 4使用PDP随机分配作为结构模型中的工具变量，估计药物变化和停药对健康结果的影响。我们将研究医生、养老院管理人员和长期护理药房报道的七种药物：骨质疏松症药物、血管紧张素受体阻滞剂（ARBs）、非典型抗精神病药、抗抑郁药、胆碱酯酶抑制剂、长效阿片类药物和雾化吸入剂。我们将研究可能与这些药物使用中断相关的健康结果，包括骨折、因心脏并发症住院、幻觉或妄想、行为、抑郁症状、认知表现、功能状态和疼痛。我们将估计三项式回归模型、逻辑回归模型、线性回归模型和两阶段最小二乘回归模型的组合来解决这些目标。公共卫生相关性：根据医疗保险D部分，老年双重资格养老院居民——有巨大医疗需求和有限财政资源的人群——被随机分配到PDP，而不考虑其当前药物的覆盖范围。我们的研究将首次全面评估PDP覆盖慷慨对双重资格养老院居民药物使用和健康结果的影响。这项研究的结果将有助于联邦和州决策者评估D部分可能发生的变化，以及负责居民护理的其他关键利益相关者，如养老院管理者、照顾养老院居民的医生和长期护理药房。

DESCRIPTION (provided by applicant): The Medicare Part D prescription drug benefit dramatically changed how prescription drugs are financed and administered in nursing homes, particularly for the two-thirds of residents who are dually eligible for Medicare and Medicaid ("dual eligibles"). While Medicaid formerly covered drugs for dual-eligible nursing home residents, these individuals are now randomly assigned to private prescription drug plans (PDP). PDPs vary with respect to formulary coverage and utilization management techniques for specific medications. As a result, some dual-eligible nursing home residents are randomized to PDPs with generous coverage of their current medications and others to PDPs with more restrictive coverage. There have been no empirical studies of the impact of PDP generosity on the health and well-being of dual-eligible nursing home residents. To assess the impact of PDP generosity on medication use and resident health outcomes, we propose to use drug utilization data from a large long term care pharmacy in combination with data on health outcomes from the Minimum Data Set (MDS) and Medicare Part A hospitalization claims for the period 2005-2008 (one year before and three years after Part D implementation). The specific aims of this application are to: 1) construct medication-specific measures of the generosity of coverage for each PDP to which a dual-eligible nursing home resident was randomly assigned; 2) examine the impact of PDP generosity on medication changes and discontinuations; 3) examine the impact of PDP generosity on health outcomes; and 4) assess the impact of medication changes and discontinuations on health outcomes. Aims 2 and 3 take advantage of the randomization of dual eligibles to PDPs to estimate effects of generosity on medication use and outcomes that are uncontaminated by selection bias. To determine if medication disruptions are a mechanism through which PDP generosity affects health outcomes, Aim 4 uses the random assignment to PDPs as an instrumental variable in a structural model estimating the effect of medication changes and discontinuations on health outcomes. We will examine seven classes of medications for which physicians, nursing home administrators, and long term care pharmacies have reported coverage restrictions for some PDPs: osteoporosis medications, angiotensin receptor blockers (ARBs), atypical antipsychotics, antidepressants, cholinesterase inhibitors, long-acting opioids, and nebulized inhalants. We will study health outcomes that could be related to disruptions in use of these medications, including fractures, hospitalization for cardiac complications, hallucinations or delusions, behavior, depressive symptoms, cognitive performance, functional status, and pain. We will estimate a combination of trinomial regression models, logistic regression models, linear regression models, and two-stage least squares regression models to address these aims. PUBLIC HEALTH RELEVANCE: Under Medicare Part D, elderly dual-eligible nursing home residents -- a population with great medical need and limited financial resources -- are randomly assigned to a PDP without consideration of its coverage of their current medications. Our study will provide the first comprehensive assessment of the impact of PDP coverage generosity on medication use and health outcomes for dual-eligible nursing home residents. The results of this study will be useful to federal and state policymakers in assessing possible changes to Part D and to other key stakeholders responsible for resident care, such as nursing home administrators, physicians who care for nursing home residents, and long term care pharmacies.