Impact of a Pharmacy Care Management Service on Health Spending, Resource Use, and Medication Adherence for Medically Complex Medicare Advantage Members

BACKGROUNDThe Medicare Advantage (MA) program has grown rapidly over the past two decades, particularly among medically complex beneficiaries, which has implications for healthcare utilization, costs, and quality in the MA program. Ensuring safe and effective medication use in this population has been identified as a priority by policymakers, yet there is limited evidence to guide MA plans pharmacy care management efforts. OBJECTIVETo evaluate the impact of an integrated pharmacy care management (PCM) program implemented at a regional Medicare Advantage and Part D (MAPD) plan on 12-month cost outcomes, health services use, and medication adherence quality measures for polypharmacy members enrolled in the program as well as for a subgroup predicted to have high potential cost savings from improved medication adherence. METHODSWe conducted a retrospective cohort study using adjudicated administrative claims data and multi-stage matching methods. The PCM program was offered by telephone to MAPD members who had filled eight or more chronic medications in the 180 days prior to being screened for eligibility. The PCM cohort consisted of individuals enrolled in the PCM program who filled at least one prescription after enrollment, had no evidence of hospice care, and were continuously eligible for health plan benefits for at least 12 months before and 12 months after enrollment. Potential controls were members who met the same criteria but who did not participate in the PCM program and filled prescriptions at non-PCM pharmacies. A commercially available algorithm (the Value of Future Adherence [VFA] score) was used to predict potential future cost savings associated with improved medication adherence for all members at baseline. Control members were matched to PCM members in a 5:1 ratio using a two-stage matching process. Outcomes were measured over 12 months and included per enrollee per month (PEPM) health spending, health resource utilization, and medication adherence for oral diabetes medications, renin-angiotensin system antagonists, and statins. Outcomes were assessed for all members and in the subgroup with high VFA scores. RESULTSA total of 724 PCM members matched to 3,620 control members, with 196 members in the high VFA subgroup. Among all PCM members, there was a $50 (95% CI: $15, $86; p=0.005) PEPM increase in average pharmacy spending compared to controls, and an offsetting $158 (95% CI: -$265, -$51; p=0.004) PEPM decrease in average medical spending, resulting in a $108 (95% CI: -$221, $5; p=0.062) PEPM lower average total cost of care in PCM members after 12 months. Savings were driven primarily by the high VFA subgroup, which incurred an average of $52 (95% CI: -$19, $130; p=0.187) PEPM greater pharmacy spending and $458 (95% CI: -$678, -$233; p<0.001) PEPM less medical spending than controls, for an average decrease of $406 (95% CI: -$645, -$161; p<0.001) PEPM in total cost of care. PCM members experienced a 15% (p=0.008) reduction in inpatient stays compared to control members; high VFA PCM members had 32% (p<0.001) fewer inpatient stays. The PCM program was associated with increases in the percent of members adherent to renin-angiotensin system antagonist, statin, and oral antidiabetic therapy, ranging from 7.3 to 12.9 (p<0.001) percentage points among all PCM members and 12.2 to 14.3 (p<0.05) percentage points for high VFA members. CONCLUSIONThe PCM program was associated with significantly lower medical spending, reduced hospital admissions, and improved adherence to chronic medications in members receiving the program for 12 months. Benefits of the program are greatest among members in the high VFA subgroup. Our findings support the value of an integrated pharmacy care management program in the polychronic MAPD population and underscore the value of targeting the PCM program to members predicted to benefit the most rather than merely on the basis of the number of medications a member is taking.