3144 — Veterans' Pharmacy and Healthcare Utilization following Implementation of the Medicare Part D Pharmacy Benefit
Stroupe KT, Hines VA Hospital; Bailey L, Hines VA Hospital; Gellad WF, VA Pittsburgh Healthcare System; Suda K, Hines VA Hospital; Huo Z, Hines VA Hospital; Martinez R, Hines VA Hospital; Burk M, VA Pharmacy Benefit Management Services; Cunningham F, VA Pharmacy Benefit Management Services; Smith BM, Hines VA Hospital;
Because > 40% of VA users are Medicare enrolled, a substantial portion of VA users are eligible for Medicare Part D drug benefits, which became available January 2006. We examined the association of Part D enrollment with changes in VA pharmacy use and VA and Medicare-reimbursed healthcare use.
We included all women and a random 10% sample of men enrolled in VA who were > 65 years old by January 2004 and alive through December 2007. A difference-in-differences approach was used to examine changes in utilization between 2005 (before) and 2007 (after Part D was implemented) by Part D-enrolled Veterans compared to non-enrollees. Pharmacy use was measured as the number of 30-day equivalent medication supplies. We implemented this using propensity score methods within GEE models.
Of 181,997 Veterans, 49,882(21.5%) were enrolled in Part D during 2007. VA 30-day supplies decreased from 26.2 to 23.4 among enrollees but increased from 36.6 to 37.4 among non-enrollees (weighted difference-in-differences: -4.0, p < 0.001), indicating a 15% (4/26.2) decrease. Enrollees with copayments for some or all VA medications had -4.6 (99%CI:-5.2,-4.0) and -4.0 (99%CI:-4.4,-3.5) reductions in 30-day supplies compared to non-enrollees, representing 14% and 23% decreases. Non-overlapping 99%CIs indicated these reductions were significantly different than for Veterans without VA copayments (0.19;99%CI:-2.6,3.0). For enrollees with no, low, moderate, or high VA pharmacy use in 2005, there were reductions of -0.5 (99%CI:-0.8,-0.3), -3.5 (99%CI:-4.2,-2.8), -7.8 (99%CI:-8.6,-7.0), and -8.0 (99%CI:-10.1,-6.3) 30-day supplies compared to non-enrollees. Compared to non-enrollees, enrollees dually using VA/Medicare outpatient services in 2005 had a greater decrease in VA pharmacy use (-6.4, 99%CI:-7.0,-5.7) than VA-only (-0.9, 99%CI:-1.2,-0.6) or Medicare-only (-3.6, 99%CI:-5.2,-2.0) outpatient users. The number of VA outpatient visits decreased, while the number of Medicare-reimbursed outpatient visits increased for enrollees compared to non-enrollees.
Veterans' enrollment in Medicare Part D was associated with reductions in medications obtained from VA pharmacies and changes in VA and non-VA healthcare use.
As healthcare reform efforts proceed with implementation of the ACA and the Choice Act, it is important for clinicians and policymakers to consider that enhanced access to non-VA services may impact patterns of healthcare use across systems of care.