Medications on Health Care Costs in a Medicare Advantage Prescription Drug Plan Population management tool on patient outcomes and health plan costs has not been well researched in antidiabetic class management. The present study helps to fill this gap by evaluating the impact of PA for branded type 2 diabetes agents on health care costs and subsequent treatment patterns. ■■ Methods Data Source A retrospective cohort study was conducted using member enrollment, medical and pharmacy claims, and laboratory data from a large national Medicare Advantage Prescription Drug (MAPD) plan population. Member enrollment data include information on member demographics and coverage start and end dates. Medical claims data include detailed information on physician visits, outpatient visits, and hospital inpatient stays. Pharmacy claims data include detailed information on each member’s prescription fill. Such information includes, but is not limited to, the specific medication filled (National Drug Codes [NDCs] and Generic Product Identifier [GPI] codes); prescription fill date; quantity dispensed; days supply; member out-of-pocket costs for the prescription; the amount the plan paid for the prescription; and medications that were denied at the place of service (POS). Laboratory claims (including the cost of the test) are available for all plan members with medical benefits; for the percentage of patients receiving those services at laboratories that provide results directly to the health plan, the measurement values (results) can also be linked to the claim. An Institutional Review Board exemption letter was granted by the Western Institutional Review Board. Prior Authorization Members within the health plan who request prescriptions for medications requiring PA must go through a specific process to receive approval. Typically, the member’s health care provider must submit a form, which is faxed to the health plan and evaluated by a staff pharmacist. The pharmacist then reviews this information in combination with the member’s pharmacy claims data to determine whether the member meets the criteria for the medication. On occasion, a member might not meet 1 or more criteria, but may obtain approval through a grievance and appeal process, wherein a medical director reviews and approves the medication requiring. Once the authorization is granted, the health plan will cover the cost of the medication. Study Design and Sample Members with type 2 diabetes mellitus (T2DM), aged 18 to 89 years, with a denied pharmacy claim for a branded medication for this disease requiring PA between January 1, 2008, and June 30, 2009 (intake period), were included in the study. Sitagliptin (DPP-4 inhibitor) and exenatide (incretin mimetic) were the 2 branded medications requiring PA at the time of the study. (GPI codes are listed in Appendix A, available online.) The date of the first denied claim for a type 2 diabetes medication during the intake period was considered the index date, and subjects were required to have 12 months of continuous enrollment both before and after the index date. The entire study period was 24 months in duration, including a 12-month pre-index period and a 12-month post-index period. Those with gestational diabetes—identified by an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 648.8 (abnormal glucose tolerance of mother complicating pregnancy, childbirth, or the puerperium) during the 12-month pre- or post-index period— were also excluded, as were individuals with a Type 1 diabetes mellitus (T1DM) diagnosis (ICD-9-CM code 250.x1 or 250.x3) in the absence of at least 1 T2DM diagnosis (ICD-9-CM code 250.x0 or 250.x2) any time during the study period. The latter exclusion criterion was applied to maximize the likelihood of identifying T1DM patients without excluding true T2DM patients who had received an erroneous diagnosis of T1DM at some point during their medical history, as the alternating fourth-digit coding for diabetes may produce misclassification of T1DM and T2DM. Finally, members with a claim in the previous 12 months for any branded type 2 diabetes medication requiring PA were excluded from the present study in order to capture only newly initiating users. Members were assigned to 1 of 3 cohorts, based first on whether they had a subsequent paid pharmacy claim for the same branded medication requiring PA, and second on whether their claims showed that they met the health plan’s criteria for reimbursement of the medication. If the member did have at least 1 paid pharmacy claim during the first 45 days of the post-index period, it was determined that the member met the criteria and was authorized to receive reimbursement for the medication; such members were placed in the received authorization cohort. Members who had a paid pharmacy claim beyond the first 45 days were excluded from analysis because there may have been changes in their qualifying characteristics during the extended delay that would be difficult to measure and because it was necessary to put some time constraint around the length of follow-up for practical purposes. Next, the medication profiles of the members who did not have subsequent paid claims for the branded type 2 diabetes medication requiring PA were checked to see if these members would meet the health plan’s 2011 criteria for these medications. It was necessary to run the claims through a new set of criteria since the pharmacy processing data that recorded the actual approval of authorization and the supporting information used to assess eligibility (e.g., physician fax forms, review of fill patterns, and other documentation from health care practitioners) from 2008-2009 were not available. The 2011 criteria were identical to the 2008 and 2009 criteria except for the removal of insulin use as an exclusionary call me for detile mob :01711239682
Posted on: Mon, 12 Aug 2013 10:44:51 +0000
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