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Underreporting High-Risk Prescribing Among Medicare Advantage Plans: A Cross-sectional Analysis

Alicia L. Cooper, MPH, PhD; Lewis E. Kazis, ScD; David D. Dore, PharmD, PhD; Vincent Mor, PhD; and Amal N. Trivedi, MD, MPH
[+] Article, Author, and Disclosure Information

From Department of Vermont Health Access, Williston, Vermont; Providence Veterans Affairs Medical Center and Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island; Center for the Assessment of Pharmaceutical Practices, Boston University School of Public Health, Boston, Massachusetts; and Center for Health Quality, Outcomes and Economic Research, Edith Nourse Rogers Memorial Hospital Veterans Affairs Medical Center, Bedford, Massachusetts.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.

Grant Support: By the Health Assessment Lab (Alvin R. Tarlov & John E. Ware Jr. Doctoral Dissertation Award in Patient Reported Outcomes) and the National Institute on Aging (5RC1AG036158).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2961.

Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Cooper (e-mail, alicia.cooper@va.gov). Data set: Not available.

Requests for Single Reprints: Amal N. Trivedi, MD, MPH, Department of Health Services, Policy and Practice, Brown University, Box G-S121-6, Providence, RI 02912; e-mail, amal_trivedi@brown.edu.

Current Author Addresses: Dr. Cooper: Department of Vermont Health Access, 312 Hurricane Street, Suite 201, Williston, VT 05495.

Dr. Kazis: Department of Health Policy and Management, Boston University School of Public Health (T-3W), 715 Albany Street, Talbot Building, Boston, MA 02118.

Dr. Dore: Department of Health Services, Policy and Practice, Department of Epidemiology, Brown University, Box G-S121-7, Providence, RI 02912.

Dr. Mor: Department of Health Services, Policy and Practice, Brown University, Box G-S121-7, Providence, RI 02912.

Dr. Trivedi: Department of Health Services, Policy and Practice, Brown University, Box G-S121-6, Providence, RI 02912.

Author Contributions: Conception and design: A.L. Cooper, L.E. Kazis, V. Mor, A.N. Trivedi.

Analysis and interpretation of the data: A.L. Cooper, L.E. Kazis, D.D. Dore, V. Mor, A.N. Trivedi.

Drafting of the article: A.L. Cooper, A.N. Trivedi.

Critical revision of the article for important intellectual content: A.L. Cooper, L.E. Kazis, D.D. Dore, V. Mor, A.N. Trivedi.

Final approval of the article: A.L. Cooper, L.E. Kazis, D.D. Dore, V. Mor, A.N. Trivedi.

Statistical expertise: L.E. Kazis, D.D. Dore, V. Mor.

Obtaining of funding: A.L. Cooper, A.N. Trivedi.

Administrative, technical, or logistic support: V. Mor.

Ann Intern Med. 2013;159(7):456-462. doi:10.7326/0003-4819-159-7-201310010-00005
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Chinese translation

Background: Although Medicare Advantage plans are required to report clinical performance using Healthcare Effectiveness Data and Information Set (HEDIS) quality indicators, the accuracy of plan-reported performance rates is unknown.

Objective: To compare calculated and reported rates of high-risk prescribing among Medicare Advantage plans.

Design: Cross-sectional comparison.

Setting: 172 Medicare Advantage plans.

Patients: A random sample of beneficiaries in 172 Medicare Advantage plans in 2006 (n = 177 227) and 2007 (n = 173 655).

Measurements: Plan-reported HEDIS rates of high-risk prescribing among elderly persons were compared with rates calculated from Medicare Advantage plans’ Part D claims by using the same measure specifications and source population.

Results: The mean rate of high-risk prescribing derived from Part D claims was 26.9% (95% CI, 25.9% to 28.0%), whereas the mean plan-reported rate was 21.1% (CI, 20.0% to 22.3%). Approximately 95% of plans underreported rates of high-risk prescribing relative to calculated rates derived from Part D claims. The differences in the calculated and reported rates negatively affected quality rankings for the plans that most accurately reported rates. For example, the 9 plans that reported rates of high-risk prescribing within 1 percentage point of calculated rates were ranked 43.4 positions lower when reported rates were used instead of calculated rates. Among 103 680 individuals present in both the sample of Part D claims and HEDIS data in 2006, Medicare Advantage plans incorrectly excluded 10.3% as ineligible for the HEDIS high-risk prescribing measure. Among those correctly included in the high-risk prescribing denominator, the reported rate of high-risk prescribing was 21.9% and the calculated rate was 26.2%.

Limitation: A single quality measure was assessed.

Conclusion: Medicare Advantage plans underreport rates of high-risk prescribing, suggesting a role for routine audits to ensure the validity of publicly reported quality measures.

Primary Funding Source: Health Assessment Lab and National Institute on Aging.


Grahic Jump Location
Figure 1.

Study flow diagram.

HEDIS = Healthcare Effectiveness Data and Information Set; HOS = Health Outcomes Survey.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Calculated and reported rates of high-risk prescribing in Medicare Advantage plans in 2006 and 2007.

Each point represents a single Medicare Advantage plan. CMS = Centers for Medicare & Medicaid Services. Points below the diagonal line represent plans that underreported rates of high-risk prescribing.

Grahic Jump Location
Grahic Jump Location
Figure 3.

Comparison of ranks from reported versus calculated rates of high-risk prescribing.

The 172 plans are arrayed from most accurate reporting (upper quadrants I and II show the smallest difference between calculated and reported rates) to least accurate reporting (lower quadrants III and IV show the largest difference between calculated and reported rates). Plans in left quadrants I and IV are ranked worse when using reported values; plans in right quadrants II and III are ranked better when using reported values.

Grahic Jump Location




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Submit a Comment/Letter
Posted on October 17, 2013
Ronald A. Fronduti, MD
West Chester, PA
Conflict of Interest: None Declared
The article by Cooper, “Underreporting High Risk Prescribing among Medicare Advantage Plans” and accompanying editorial decry lower than expected reporting rates. Yet the all-inclusive nature of the reporting requirements renders the data useless. The use of a single drug from the high risk list at low dose in a healthy sixty five year old is as reportable as the use of multiple drugs at high dose in a frail octogenarian. The article by Pugh sited noted a dose response, that is, higher numbers of high risk drugs were associated with higher risk of acute care. Also noted in that article were studies of drug related hospital admissions showing few admissions attributed to drugs that are part of high risk list. This implies that the relationship between high risk drug prescribing and the risk of hospitalization is much more complicated that the risk derived from any individual drug prescribed. Reporting data will need to be better refined in order to provide meaningful data. Until that happens, the data collected will be of little practical use.

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