Cost-related Medication Nonadherence among Medicare Beneficiaries with Cardiovascular Disease Risk Factors: The Role of Comprehension of the Medicare Program and its Prescription Drug Benefits

RATIONALE, AIMS, AND OBJECTIVES: This study aims to investigate how reported comprehension of the Medicare program and its prescription drug benefits affects cost-related medication nonadherence (CRN) among Medicare beneficiaries with cardiovascular disease (CVD) risk factors. METHODS: This cross-sectional study used the 2017 Medicare Current Beneficiary Survey Public Use File data and included Medicare beneficiaries aged ≥ 65 years who reported having at least one CVD risk factor (i.e., hypertension, hyperlipidemia, diabetes, smoking, and obesity) (n=2,821). A survey-weighted logistic model was used to examine associations between lack of difficulty understanding the Medicare program and its prescription drug benefits and CRN, controlling for beneficiaries’ demographic (e.g., age) and clinical characteristics (e.g, comorbidities). This study further analyzed five subgroups based on the type of CVD risk factors involved. RESULTS: Among Medicare beneficiaries with CVD risk factors, 14.4% reported CRN. Medicare beneficiaries with CVD risk factors who reported difficulty understanding the overall Medicare program and its prescription drug benefits were more likely to report CRN, compared to those who reported easy understanding of the overall Medicare program (OR=1.49; 95% CI=1.09, 2.04; p<0.001) and its prescription drug benefits (OR=2.01; 95% CI=1.51, 2.67; p<0.001). Similar results were obtained for the subgroups with obesity, hypertension, or hyperlipidemia. CONCLUSIONS: Perceived lack of difficulty understanding the Medicare Program and its prescription drug benefits has a positive impact on CRN reduction among Medicare beneficiaries with CVD risk factors, especially those with obesity, hypertension or hyperlipidemia. Monitoring and enhancing Medicare beneficiaries’ overall understanding of the Medicare program may reduce CRN.

823. Characteristics, Comorbidities, and Medication Burden among People Living with HIV in the U.S. Medicare Program

Background Among the 1.2 million people living with HIV (PLWH) in the U.S., many are covered by Medicare, a federally funded health insurance program for elderly (≥65 years) and disabled (&lt; 65 years) individuals. Medicare has emerged as a major source of HIV care for PLWH. Given limited research in this population, a better understanding of patient characteristics, comorbidities, and comedication use among PLWH in the Medicare program is needed to help optimize clinical care. Methods A retrospective claims analysis of a national cross-sectional sample of fee-for-service (FFS) Medicare beneficiaries with continuous medical and prescription coverage in 2018 was conducted using 100% Medicare administrative claims. The PLWH group included individuals with ≥1 HIV diagnosis code in medical claims and ≥1 pharmacy claim for an anchor antiretroviral (ARV) drug (i.e., NNRTI, PI or InSTI) in 2018. The comparison group included a random sample of Medicare beneficiaries without HIV (PLWoH). Sociodemographic characteristics, comorbidities, and medication use were compared between PLWH and PLWoH. Results The study sample included 86,856 PLWH and 552,645 PLWoH. PLWH were more likely to be younger (mean age: 57.4 vs 71.1 years and &lt; 65 years: 72% vs 18%), male (75% vs 42%), Black (42% vs 10%), eligible for Medicare due to disability (83% vs 27%) and receiving full low-income subsidies (77% vs 31%); all p&lt; 0.001. Prevalence of &gt;3 comorbidities was high in PLWH (70.2%) and only slightly lower than in PLWoH (71.7% p&lt; 0.001). Prevalence of neuropsychiatric conditions, chronic kidney disease, liver disease, COPD, hepatitis B, and hepatitis C were higher in PLWH (Figure 1). The mean hierarchical condition categories risk score was higher in PLWH vs PLWoH (1.81 vs. 1.32; p&lt; 0.001). On average, polypharmacy was higher among PLWH vs PLWoH (annual number of unique medications: 12.6 vs. 9.4 for all drugs and 10.3 vs. 9.4 for non-ARV drugs, both p&lt; 0.001). Figure 1. Percentage of PLWH and PLWoH with multimorbidity and selected comorbid conditions. Abbreviations: COPD=chronic obstructive pulmonary disease; GI=gastrointestinal; PLWH=people living with HIV; PLWoH=people living without HIV All p-values &lt;0.001 except GI Disorders (p=0.14). Conclusion In the Medicare FFS population, multimorbidity and polypharmacy were highly prevalent in PLWH despite their substantially younger age compared to PLWoH. Our findings highlight the need to consider comorbidities and comedications in HIV management including ARV regimens to minimize medication burden and drug interactions, which might improve clinical outcomes. Disclosures Pengxiang Li, PhD, Avalon Health Economics LLC (Consultant)COVIA Health Solutions (Consultant)Healthstatistics, LLC (Consultant) Jianbin Mao, PhD, Merck (Employee)Merck (Shareholder) Girish Prajapati, M.B.B.S., MPH , Merck & Co., Inc. (Employee, Shareholder) Robert Gross, MD, MSCE, Pfizer (Other Financial or Material Support, Serve on DSMB for drug unrelated to HIV) Jalpa A. Doshi, PhD, Acadia (Consultant, Advisor or Review Panel member)Allergan (Advisor or Review Panel member)Biogen (Grant/Research Support)Boehringer Ingelheim (Other Financial or Material Support, Scientific lecture)Catabasis (Consultant)Humana (Grant/Research Support)Janssen, Inc. (Consultant, Grant/Research Support)MeiraGTX (Consultant)Merck (Grant/Research Support, Advisor or Review Panel member)Novartis (Grant/Research Support)Otsuka (Advisor or Review Panel member)Regeneron (Grant/Research Support)SAGE Therapeutics (Consultant)Sanofi (Grant/Research Support)Shire (Advisor or Review Panel member)The Medicines Company (Advisor or Review Panel member)

Variation in influenza vaccine assessment, receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes

ABSTRACT Background: More older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents. Methods: We analyzed 2014-2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three groups. We examined three NH-level outcomes: percentage of residents assessed and appropriately provided the influenza vaccine, receiving influenza vaccine, and refusing influenza vaccine. Results: There were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n=4131 NHs), moderate (3.4% to 18.6%; n=4127 NHs) and high (>18.6%; n=4126 NHs). Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.7%, P<0.0001), or high (3.1%, P<0.0001) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.1%, P<0.0001), or high (-4.6% P<0.0001) MA compared with NHs with the lowest prevalence of MA. Among 753,616 short-stay residents in 12,205 NHs, there was no association between MA concentration and influenza vaccination receipt but vaccine refusal was greater in NHs with higher MA prevalence (high or moderate vs. low MA: 5.2%, P<0.0001). Conclusion: The relationship between MA concentration and influenza vaccination measures varied among post-acute and long-term NH residents. As MA takes a larger role in the Medicare program, and more MA beneficiaries enter NHs, there is need to consider how managed care can be leveraged to improve the delivery of preventive services such as influenza vaccinations in NH settings.

Medicare’s Stewardship Role to Improve Care Delivery: Opportunities for the Biden Administration

Medicare initiatives have been instrumental in improving care delivery and payment, as exemplified by its role in broadly expanding the use of telehealth during the COVID pandemic. Medicare innovations have been adopted or adapted in Medicaid and by private payers, while Medicare Advantage plans successfully compete with TM only because their payment rates are tied by regulation to those in the traditional Medicare program. However, Medicare has not succeeded in implementing new, value-based payment approaches that also would serve as models for other payers, nor has Medicare succeeded in improving quality by relying on public reporting of measured performance. It is increasingly clear that burdensome attention to measurement and reporting distracts from what could be successful efforts to actually improve care through quality improvement programs, with Medicare leading in partnership with providers, other payers, and patients. Although Congress is unlikely to adopt candidate Biden’s proposals to decrease the eligibility age for Medicare or adopt a public option based on Medicare prices and payment methods in the marketplaces, the incoming Biden administration has an opportunity to provide overdue, strategic direction to the pursuit of value-based payments and to replace failed pay-for-performance with provider-managed projects to improve quality and reduce health disparities.