Disparity Implications of the Eligibility Criteria for Medication Therapy Management Services among the Non-Medicare Population Junling Wang, Ph.D., Lawrence M. Brown, Pharm.D., Ph.D. Song Hee Hong, Ph.D. Associate Professors Division of Health Outcomes and Policy Research The University of Tennessee College of Pharmacy 1

Presenter Disclosures (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Junling Wang, Ph.D. No relationships to disclose.

Background Medicare Prescription Drug Improvement and Modernization Act (Medicare Modernization Act or MMA) took effect in [1] Medication therapy management (MTM) services to be provided as part of the prescription drug (Part D) benefits as required by the Centers for Medicare and Medicaid Services (CMS). Three eligibility criteria for MTM services: ◦ Have multiple chronic conditions ◦ Use multiple covered drugs ◦ Be likely to incur over $4,000 in drug costs 1. Centers for Medicare & Medicaid Services. Department of Health and Human Services. Medicare Program; Medicare prescription drug benefit. Final rule. Fed Regist. 2005;70:

Background MTM is a “distinct service or group of services that optimize therapeutic outcomes for individual patients.” Provided by licensed pharmacists or other qualified health care providers. 4

Background Beneficial for patients with chronic conditions such as hypertension, and diabetes. Prevalence of these diseases is higher in minority populations than in Whites, including the prevalence of poor control. Thus, MTM could be an important tool for reducing outcome disparities. 5

Background Health insurance plans other than Medicare Part D plans have also implemented MTM programs. Some have included similar components of the Part D MTM eligibility criteria, [2,3] since Medicare is the nation’s leading purchaser and regulator of health care. 2. Schommer JC, et al. Pharmacist-provided medication therapy management (part 2): payer perspective in J Am Pharm Assoc. 2008;48: Wisconsin Pharmacy Quality Collaborative Wisconsin Pharmacy Quality Collaborative Medication Therapy Management Services Program. Accessed at: http: //ww.pswi.org/professional/WPQC%20Program%20Description.pdf, October 25, 2011./ww.pswi.org/professional/ 6

Background Historically, racial and ethnic minorities have been found to use fewer prescription drugs and incur lower drug costs than do Whites. Our recently published analyses of historical data before Part D implementation demonstrated that among the Medicare population, racial and ethnic minorities are less likely to be eligible for MTM services than are Whites (non-Hispanic Blacks, 21-34% lower; Hispanics, 32-38% lower). [4] 4. Wang J, et al. Disparity implications of Medicare eligibility criteria for medication therapy management services. Health Serv Res. 2010;45:

Study Objectives To examine whether there are racial and ethnic disparities in the likelihood of meeting MTM eligibility criteria among non- Medicare beneficiaries, ◦ According to 2008 eligibility criteria. ◦ According to eligibility criteria ◦ Among individuals with hypertension, heart disease and diabetes. 8

Methods Medical Expenditure Panel Survey ( ). ◦ A federal survey carried out by the Agency for Healthcare Research and Quality. ◦ With the purpose of providing information on national health services utilization and expenditures from a national representative sample of non-institutionalized civilians. 9

Methods MTM eligibility criteria were designed to be flexible and to evolve. May examine lower limit, median, mode, and upper limit values for the eligibility criteria. For 2008, for the limits based on ◦ The number of covered prescriptions - 2, 5, 5,15. ◦ The number of chronic conditions - 2, 3, 3, 5. ◦ Part D drug costs ≥$4,000 (constant). Nine possible threshold combinations ◦ Median values for main analysis. ◦ All other combinations in sensitivity analyses. 10

Methods For criteria ◦ Allowable minimum number of covered prescriptions was lowered to 8 (2, 5, 8, 8). ◦ Allowable minimum number of chronic conditions was lowered to 3 (2, 3, 3, 3). ◦ Part D drug costs ≥$3,000 (constant). ◦ Six possible combinations  One in main analysis, five in sensitivity analyses. 11

Methods Survey-weighted chi-square test ◦ Compared the proportions of individuals meeting MTM eligibility criteria across racial and ethnic groups. Survey weighted logistic regression ◦ Adjusted for confounding factors. ◦ Predisposing, enabling, and need factors in Anderson’s Behavioral Model of Health Services Utilization.  Age, gender, marital status, poverty categories, highest degree received, health insurance, geographic regions, metropolitan statistical area, and self-perceived health status. 12

Results 13

WhitesBlacksHispanics No.% % % Age: , , , , , , , , , >50 5, , , Income: Poor 1, , , Near Poor Low Income 1, , , Middle Income 5, , , High Income 7, , , Table 1. Socio-demographic characteristics across racial and ethnic groups. 14

Table 1. Socio-demographic characteristics across racial and ethnic groups (continued) WhitesBlacksHispanics No.% % % Education: < High School2, , , High School7, , , College Degree3, > College Degree1, Other1, Self-perceived health status: Excellent4, , , Very Good5, , , Good4, , , Fair1, , Poor

AnalysesNo. of Drugs No. of Conditions GroupsNo. Eligible% Eligible Main>=5>=2Whites Blacks Hispanics Sensi. 1>=5>=3Whites Blacks Hispanics Sensi. 2>=5 Whites Blacks Hispanics Sensi. 3>=2>=3Whites Blacks Hispanics Sensi. 4>=2 Whites Blacks Hispanics Table 2. Number and percentage eligible for MTM services according to the main analysis and various sensitivity analyses 16

Coefficient Estimate POdds Ratio Lower Limit of the CI for OR Upper Limit of the CI for OR Unadjusted Model Blacks Hispanics-0.91< Adjusted Model Blacks Hispanics-0.62< Table 3. Racial and ethnic disparities in the likelihood of meeting MTM eligibility criteria according to logistic regression for the main analysis for 2008 criteria (reference group: whites) 17

Figure 1. Odds ratios for meeting the 2008 MTM eligibility criteria. 18

Figure 2. Odds ratios for meeting the 2008 MTM eligibility criteria in the subpopulation with the three chronic conditions. 19

Discussions and Conclusions Blacks and Hispanics are less likely than Whites to be eligible for MTM eligibility criteria among the non-Medicare population. Medicare eligibility criteria have disparity implications among the non-Medicare population. Due to the catalyst role for Medicare, the eligibility criteria for MTM services need to be changed first for Medicare. 20

Discussions and Conclusions MTM eligibility criteria is a value-based strategy because those eligible have more complex medical conditions and have greater potential to benefit from MTM services. However, value-based strategy are oftentimes in conflict with equity doctrine. Policy makers need to be careful when setting value-based strategies. 21

Discussions and Conclusions Future research should examine the health implications of the disparities in meeting MTM eligibility criteria. Future research should also examine strategies of eliminating disparities in meeting MTM eligibility criteria. 22

Acknowledgements Research assistance: Songmei Meng, M.S., and Kiraat D. Munshi, M.S. Funding: This study was funded by the Pharmaceutical Research and Manufacturers of America Foundation Health Outcomes Research Starter Grant. 23

Contact Information: Junling Wang, Ph.D. Division of Health Outcomes and Policy Research, University of Tennessee College of Pharmacy Phone: