Walid F. Gellad, MD, MPH; Julie M. Donohue, PhD; Xinhua Zhao, PhD; Maria K. Mor, PhD; Carolyn T. Thorpe, PhD, MPH; Jeremy Smith, MPH; Chester B. Good, MD, MPH; Michael J. Fine, MD, MSc; Nancy E. Morden, MD, MPH
Disclaimer: This article represents the opinions of the authors and does not necessarily represent the views of the U.S. Department of Veterans Affairs or the U.S. government.
Acknowledgment: The authors thank Hal Sox, MD, for his comments on a previous draft of the manuscript.
Grant Support: Dr. Gellad was supported by Veterans Affairs Health Services Research & Development (CDA 09-207 and LIP 72-057) and Veterans Affairs Competitive Pilot Project Fund (XVA 72-156). Drs. Gellad and Donohue were jointly supported by the RAND–University of Pittsburgh Health Institute and the National Center for Research Resources, a component of the National Institutes of Health (UL1 RR024153). Dr. Donohue was supported by the Agency for Healthcare Research and Quality (R01HS017695). Dr. Morden and Mr. Smith were supported by the National Institutes of Health/National Institute on Aging (P01 AG019783 “Causes and Consequences of Health Care Efficiency”) and the Robert Wood Johnson Foundation Dartmouth Atlas (Project 059491).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-3073.
Reproducible Research Statement: Study protocol: Available from Dr. Gellad (e-mail, email@example.com). Statistical code: Not available. Data set: Available from the U.S. Department of Veterans Affairs and Centers for Medicare & Medicaid Services with the proper agreements.
Requests for Single Reprints: Walid F. Gellad, MD, MPH, Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, 7180 Highland Drive, Pittsburgh, PA 15206; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Gellad, Zhao, Mor, Good, and Fine: Veterans Affairs Center for Health Equity Research and Promotion, 7180 Highland Drive, Pittsburgh, PA 15206.
Dr. Donohue: Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Crabtree Hall A613, Pittsburgh, PA 15261.
Dr. Thorpe: University of Pittsburgh School of Pharmacy, Department of Pharmacy and Therapeutics, 919 Salk Hall, 3501 Terrace Street, Pittsburgh, PA 15261.
Mr. Smith and Dr. Morden: The Dartmouth Institute for Health Policy & Clinical Practice, 35 Centerra Parkway, Lebanon, NH 03766.
Author Contributions: Conception and design: W.F. Gellad, J.M. Donohue, X. Zhao, C.T. Thorpe, J. Smith, M.J. Fine, N.E. Morden.
Analysis and interpretation of data: W.F. Gellad, J.M. Donohue, X. Zhao, M.K. Mor, C.T. Thorpe, J. Smith, C.B. Good, M.J. Fine, N.E. Morden.
Drafting of the article: W.F. Gellad, J.M. Donohue, C.B. Good, N.E. Morden.
Critical revision of the article for important intellectual content: W.F. Gellad, J.M. Donohue, M.K. Mor, C.T. Thorpe, M.J. Fine, N.E. Morden.
Final approval of the article: W.F. Gellad, J.M. Donohue, M.K. Mor, C.T. Thorpe, C.B. Good, N.E. Morden.
Provision of study materials or patients: W.F. Gellad, M.J. Fine, N.E. Morden.
Statistical expertise: X. Zhao, M.K. Mor, J. Smith, N.E. Morden.
Obtaining of funding: W.F. Gellad, N.E. Morden.
Administrative, technical, or logistic support: W.F. Gellad.
Collection and assembly of data: W.F. Gellad, X. Zhao, M.K. Mor, C.T. Thorpe, C.B. Good, N.E. Morden.
Gellad WF, Donohue JM, Zhao X, Mor MK, Thorpe CT, Smith J, et al. Brand-Name Prescription Drug Use Among Veterans Affairs and Medicare Part D Patients With Diabetes: A National Cohort Comparison. Ann Intern Med. 2013;159:105-114. doi: 10.7326/0003-4819-159-2-201307160-00664
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Published: Ann Intern Med. 2013;159(2):105-114.
Medicare Part D and the U.S. Department of Veterans Affairs (VA) use different approaches to manage prescription drug benefits, with implications for spending. Medicare relies on private plans with distinct formularies, whereas the VA administers its own benefit using a national formulary.
To compare overall and regional rates of brand-name drug use among older adults with diabetes in Medicare and the VA.
Medicare and the VA, 2008.
1 061 095 Medicare Part D beneficiaries and 510 485 veterans aged 65 years or older with diabetes.
Percentage of patients taking oral hypoglycemics, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) who filled brand-name drug prescriptions and percentage of patients taking long-acting insulins who filled analogue prescriptions. Sociodemographic- and health status–adjusted hospital referral region (HRR) brand-name drug use was compared, and changes in spending were calculated if use of brand-name drugs in 1 system mirrored the other.
Brand-name drug use in Medicare was 2 to 3 times that in the VA: 35.3% versus 12.7% for oral hypoglycemics, 50.7% versus 18.2% for statins, 42.5% versus 20.8% for ACE inhibitors or ARBs, and 75.1% versus 27.0% for insulin analogues. Adjusted HRR-level brand-name statin use ranged (from the 5th to 95th percentiles) from 41.0% to 58.3% in Medicare and 6.2% to 38.2% in the VA. For each drug group, the 95th-percentile HRR in the VA had lower brand-name drug use than the 5th-percentile HRR in Medicare. Medicare spending in this population would have been $1.4 billion less if brand-name drug use matched that of the VA.
This analysis cannot fully describe the factors underlying differences in brand-name drug use.
Medicare beneficiaries with diabetes use 2 to 3 times more brand-name drugs than a comparable group within the VA, at substantial excess cost.
U.S. Department of Veterans Affairs, National Institutes of Health, and Robert Wood Johnson Foundation.
Comparing the use of brand-name and generic drugs among patients receiving benefits from Medicare Part D or the U.S. Department of Veterans Affairs (VA) may help assess means of reducing costs.
In this evaluation of outpatient prescriptions, the use of brand-name drugs for treating patients with diabetes was 2 to 3 times higher in Medicare Part D than in the VA, even after adjustment for regional variations in health status. If Medicare use of generic drugs had mirrored the VA during the study period, estimated savings would have been more than $1 billion.
Large savings may be seen with greater use of generic drugs among Medicare Part D beneficiaries.
Appendix Table 1. Included Drug Groups Used by Patients
Table 1. Patient Characteristics
Appendix Table 2. Sensitivity Analysis Focusing on Men Only
Appendix Table 3. Sensitivity Analysis Excluding All Persons Enrolled in Medicare Part D From the VA Cohort
Appendix Table 4. Sensitivity Analysis Excluding All Persons Enrolled in Medicare Part D and With a Medicare Physician Office Visit From the VA Cohort
Distribution of adjusted HRR-level percentage of patients with diabetes aged 65 years or older in Medicare Part D and the VA using brand-name drugs (and insulin analogues).
Each dot is 1 HRR, and all HRR percentages are adjusted for sociodemographic and health status variables. “Statins” refers to 3-hydroxy-3-methyl coenzyme A reductase inhibitors. ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; HRR = hospital referral region; VA = Veterans Affairs.
Absolute difference, within each HRR, in adjusted percentage of patients with diabetes aged 65 years or older in Medicare Part D and the VA using brand-name drugs.
Each dot is 1 HRR, and all HRR percentages are adjusted for sociodemographic and health status variables. More positive differences indicate higher rates of brand-name use in Medicare compared with the VA in a given HRR. “Statins” refer to 3-hydroxy-3-methyl coenzyme A reductase inhibitors. ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; HRR = hospital referral region; VA = Veterans Affairs.
Table 2. Dispensed Multisource Prescriptions
Table 3. Number of Dispensed Prescriptions, Percentage of Prescriptions Dispensed as Brand-Name, and Mean Cost Per Prescription
Prescription spending and projected spending if use of brand-name drugs would change, in each of 4 drug groups among diabetes patients aged 65 years or older in Medicare Part D and the VA in 2008.
“Medicare” refers to patients enrolled in fee-for-service Parts A and B and stand-alone Part D. “Statins” refers to 3-hydroxy-3-methyl coenzyme A reductase inhibitors. ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; VA = Veterans Affairs.
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