Medication Utilization in the Medicare Population

Data sourcing

Data presented is from 2020 and is sourced directly from the Medicare Administrative Data and encoded based on the fields below. For these reports, the study population consists of Medicare fee-for-service beneficiaries ages 18+, continuously enrolled, and treated with a medication of interest during the measurement period. For more information refer directly to the data dictionary.

• RTI_RACE_CD: Beneficiary race code (modified using RTI algorithm). The race of the beneficiary and enhanced based on first and last name algorithms.
• SEX_IDENT_CD: This variable indicates the sex of the beneficiary.
• AGE_AT_END_REF_YR: This is the beneficiary’s age, expressed in years and calculated as of the end of the calendar year, or, for beneficiaries that died during the year, age as of the date of death.
• CST_SHR_GRP_CD: Monthly cost sharing group under Part D low-income subsidy. Beneficiaries receiving the subsidy at any time during the year were classified as LIS.
• ENTLMT_RSN_CURR: Current reason for Medicare entitlement. This variable indicates how the beneficiary currently qualifies for Medicare.

Medicare PQA Adherence

Conditions

• Renin Angiotensin System Antagonists (PQA PDC-RASA)
• Statins (PQA PDC-STA)
• Beta-blockers (PQA PDC-BB)
• Calcium Channel Blockers (PQA PDC-CCB)
• Adherence to Direct-Acting Oral Anticoagulants (PQA PDC-DOAC)
• Antiretroviral Medications (PQA PDC-ARV)

Metrics

• Adherence Rate: this rate measures the percentage of Medicare fee-for-service beneficiaries 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80% for the indicated medication during the measurement year.

Medicare NQF Adherence

Conditions

• Persistence of Beta-Blocker Treatment After a Heart Attack (NQF 0071)
• Adherence to Antipsychotic Medications For Individuals with Schizophrenia (NQF 1879)

Metrics

• Persistence of Beta-Blocker Treatment After a Heart Attack measures the percentage of Medicare fee-for-service beneficiaries 18 years and older during the measurement year who were hospitalized and discharged with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for six months after discharge.
• Adherence to Antipsychotic Medications For Individuals with Schizophrenia measures the percentage of Medicare fee-for-service beneficiaries 18 years and older during the measurement year with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)

Medicare Disease Measures

Conditions

• HIV cases
• Acute Myocardial Infarction (AMI) cases
• Schizophrenia cases

Metrics

• Cases per 100k: Rate of beneficiaries with the specified disease per 100,000 beneficiaries. AMI defined as beneficiaries having 1+ medical claims with ICD-10-CM of I21 HIV defined as beneficiaries having 1+ medical claims with ICD-10-CM of B20. Schizophrenia defined as beneficiaries having 1+ medical claims with ICD-10-CM of F20.
• Percent share: this figure measures a particular group's share of the total cases of the condition.
• Population percent: this figure measures a particular group's share of the total measured population: Medicare fee-for-service beneficiaries 18 years and older.

Medicare Demographic Identifiers

Race/ethnicity: Medicare enhances the race and ethnicity of each beneficiary that has been used by the Social Security Administration and applies an algorithm that identifies more beneficiaries of Hispanic and Asian descent. Due to sample size constraints and data availability, we categorized racial/ethnic groups using the following groups, and have adjusted the wording in some cases to use more inclusive terminology and to correspond more closely with our other data sources.

• Asian/Pacific Islander we represent as Asian, Native Hawaiian, and Pacific Islander (Non-Hispanic)
• American Indian / Alaska Native we represent as Indigenous (Non-Hispanic)
• Non-Hispanic White we represent as White (Non-Hispanic)
• Black or African-American we represented as Black or African American (Non-Hispanic)
• Hispanic we represent as Hispanic or Latino
• Other we represent as Unrepresented race (Non-Hispanic)
• Unknown we represent on our Unknown Demographic Map

Sex: Medicare collects the sex of each beneficiary as Unknown, Male, or Female.

Age: Medicare provides the age of each beneficiary at the end of the reference year (i.e., 2020), or, for beneficiaries that died during the year, age as of the date of death. We categorized age into the following groups:

• 18-39 years old
• 40-64 years old
• 65-69 years old
• 70-74 years old
• 75-79 years old
• 80-84 years old
• 85+ years old

Low-Income Subsidy Eligibility: The Low-Income Subsidy (LIS) program for Medicare Part D beneficiaries provides subsidies to reduce or eliminate premiums and deductibles, and offers zero to reduced co-payments for low-income Medicare Part D beneficiaries. We categorized Medicare beneficiaries, who were eligible for the Part D LIS program, for 1 or more months during 2020 as “receiving Low Income Subsidy.” Medicare beneficiaries, who were not eligible for the Part D LIS program at any time during 2020 were classified as “not receiving Low Income Subsidy.”

Entitlement Qualification: Medicare collects the reason for enrollment in Medicare. We categorized each beneficiary’s reason for Medicare enrollment as:

• Eligible due to age
• Eligible due to disability
• Eligible due to end-stage renal disease (ESRD)
• Eligible due to disability and end-stage renal disease (ESRD)

• Population Receiving Persistent Beta Blocker Treatment After a Heart Attack (Medicare Beta-Blocker Beneficiaries, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• Adherence to statins (Medicare Statins Beneficiaries, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• Adherence to beta blockers (Medicare Beta Blockers Beneficiaries, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• Adherence to RASA (Medicare RASA Beneficiaries, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• Adherence to calcium channel blockers (Medicare CCBs Beneficiaries, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• Adherence to direct oral anticoagulants (Medicare DOACs Beneficiaries, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• Acute Myocardial Infarctions (Heart Attacks) (Medicare Beneficiaries diagnosed with AMI, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• Adherence to antiretroviral medications (Medicare ARV Beneficiaries, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• New HIV diagnoses (Medicare beneficiaries, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• Adherence to anti-psychotics (Medicare beneficiaries with schizophrenia or schizoaffective disorder, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available
• Cases of Schizophrenia (Medicare beneficiaries, Ages 18+): race/ethnicity: Available; sex: Available; age: Available; low income subsidy: Available; eligibility: Available

Population Receiving Persistent Beta Blocker Treatment After a Heart Attack

Measurement definition: National Quality Forum measure representing the percentage of Medicare fee-for-service beneficiaries 18 years of age and older during the measurement year who were hospitalized and discharged with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for six months after discharge.

Source: National Quality Forum

Clinical importance: Beta-blockers are recommended by clinical guidelines for reducing the risk of a secondary heart attack.

Source: American Heart Association/American College of Cardiology Foundation

Adherence to statins

Measurement definition: Pharmacy Quality Alliance measure representing the percentage of Medicare fee-for-service beneficiaries 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80% for statins during the measurement year. A higher rate indicates better performance.

Source: PQA Alliance

Clinical importance: Statins are recommended by several treatment guidelines for the prevention of cardiovascular disease (CVD).

Source: American College of Cardiology/American Heart Association American Association of Clinical Endocrinologists/American College of Endocrinology

Adherence to beta blockers

Measurement definition: Pharmacy Quality Alliance measure representing the percentage of Medicare fee-for-service beneficiaries 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80% for beta-blockers during the measurement year. A higher rate indicates better performance.

Source: PQA Alliance

Clinical importance: Beta-blockers are recommended by clinical guidelines as a treatment for high blood pressure among some patients with coronary artery disease or heart failure.

Source: American College of Cardiology/American Heart Association

Adherence to RASA

Measurement definition: Pharmacy Quality Alliance measure representing the percentage of Medicare fee-for-service beneficiaries 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80% for renin angiotensin system antagonists (RASAs) during the measurement year. A higher rate indicates better performance.

Source: PQA Alliance

Clinical importance: RASAs are commonly prescribed to treat hypertension. The 2017 American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines recommend RASAs as first-line treatment of hypertension.

Source: American College of Cardiology/American Heart Association

Adherence to calcium channel blockers

Measurement definition: Pharmacy Quality Alliance measure representing the percentage of Medicare fee-for-service beneficiaries 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80% for calcium channel blockers during the measurement year.

Source: PQA Alliance

Clinical importance: Calcium channel blockers are recommended by clinical guidelines as first-line treatment of hypertension.

Source: American College of Cardiology/American Heart Association

Adherence to direct oral anticoagulants

Measurement definition: Pharmacy Quality Alliance measure representing the percentage of Medicare fee-for-service beneficiaries 18 years and older who met the Proportion of Days Covered (PDC) threshold of 80% during the measurement period for direct-acting oral anticoagulants.

Source: PQA Alliance

Clinical importance: DOACs are recommended by clinical guidelines among many patients with a history of ischemic stroke and atrial fibrillation.

Source: American Heart Association / American Stroke Association

Acute Myocardial Infarctions (Heart Attacks)

Measurement definition: The number of Medicare fee-for-service beneficiaries with a diagnosis of acute myocardial infarction (AMI) (otherwise known as a heart attack) per 100K during the measurement period.

Clinical importance: Heart disease, such as heart attack and heart failure, is leading cause of death in the US.

Source: CDC

Adherence to antiretroviral medications

Measurement definition: Pharmacy Quality Alliance measure representing the percentage of Medicare fee-for-service beneficiaries 18 years and older who met the Proportion of Days Covered (PDC) threshold of 90% for ≥3 antiretroviral medications during the measurement year.

Source: PQA Alliance

Clinical importance: Antiretroviral medications are recommended for the treatment of HIV.

Source: CDC

New HIV diagnoses

Measurement definition: The number of Medicare fee-for-service beneficiaries per 100K with a diagnosis of human immunodeficiency virus (HIV) during the measurement period.

Clinical importance: HIV is a major public health crisis, which disproportionately impacts certain subpopulations.

Source: CDC

Adherence to anti-psychotics

Measurement definition: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)

Source: National Quality Forum

Cases of Schizophrenia

Measurement definition: The number of Medicare fee-for-service beneficiaries per 100K with a diagnosis of schizophrenia during the measurement period.