Medicare Advantage Plans Underreport Elderly Patients Receiving Inappropriate Medications

Posted on: December 17, 2013 Topics: health law, policy & management

Nearly 95 percent of Medicare Advantage plans significantly underreport the number of elderly patients prescribed high-risk drugs, according to a study based on a quality of care measure co-authored by a BU School of Public Health professor.

elderly medication_cropped

Only nine of the 172 plans analyzed in the study came within 1 percent of their self-reported rate of high-risk medications prescribed to the elderly.

Dr. Lewis E. Kazis, a professor of health policy and management at BUSPH, collaborated with lead author Dr. Alicia Cooper and co-authors Amal Trivedi, David Dore and Vincent Mor, all from Brown University, to evaluate 172 Medicare Advantage plans. The researchers examined a measure of high-risk prescribing from the Healthcare Effectiveness Data and Information Set (HEDIS).

About 30 percent of Medicare beneficiaries are enrolled in a private managed care plan, privately-run plans that provide seniors with a managed-care approach that costs less than fee-for-service health care. The study looked at nearly 200,000 randomly sampled plan beneficiaries in 2006 and 2007, the latest years for complete datasets.

“We focused on one quality measure that involves the use of medications in the elderly – those over 65 – and the listings of drugs that are considered to be potentially inappropriate for that population,” Kazis said. “What we’re finding is that those kinds of accountability procedures that should be routinely done are not being done. I can’t speak for other measures, but I wouldn’t be surprised if others … also are not … audited as they should.”

The Centers for Medicare and Medicaid Services (CMS) control one of the largest segments of the federal budget outside of the Department of Defense. CMS uses the HEDIS data to evaluate Medicare plans and tie reimbursement and bonuses to multiple quality measures. Plans are required to report whether or not their enrollees receive one or more of the nearly 100 medicines found on a widely circulated “Drugs to Avoid” list published by the CMS. Separate studies of elderly veterans have linked these drugs to higher death and illness rates.

The researchers compared the plans’ rates of high-risk prescriptions against rates calculated from claims submitted to the Medicare prescription drug benefit program (Medicare Part D). The study found that the average rate of high-risk prescribing as reported by the plans was 21.1%, but the average rate calculated from Part D claims was 26.9%. Only nine of the 172 plans came within 1 percent of their self-reported rate.

Dr. Lewis Kazis

Dr. Lewis Kazis

Based on the findings, Kazis said, “The implication is that the plans are reporting that they’re doing better than they actually may be doing. But CMS is not auditing the plans on a regular basis. In fact, the last formal audit that CMS conducted related to this was in 1998.”

From just the quality-measure data it’s impossible to know the level at which higher risk medications are actually being over-prescribed, Kazis said.

“It’s conceivable that in cases where plans aren’t reporting more use of these drugs, greater attention should be given to providers to get a better sense of why they’re prescribing them. It’s entirely possible that there are individuals over 65 who might be on these drugs and it might be clearly necessary. But without an audit, we don’t know that.”

Amid the increased political and economic scrutiny surrounding implementation of the Affordable Care Act, “issues around accountability are going to become increasingly important going forward for plans, but also for all of health care,” Kazis said.

In an editorial accompanying the study, Matthew L. Maciejewski of Duke and Joseph T. Hanlon of the University of Pittsburgh wrote, “Having accurate information on high-risk prescribing in Medicare Advantage plans is critical because enrollment in its prescription drug plans increased 55% from 0.99 million in August 2006 (the first year examined in this study) to 1.54 million in August 2013. Medicare and Medicare Advantage enrollees would be well-served by examining whether underreporting rates in 2013 are similar to those of 2006 to 2007.”



Cooper AL, Kazis LE, Dore DD, Mor V and Trivedi AN. Underreporting high-risk prescribing among Medicare Advantage Plans: A cross-sectional analysis. Ann Intern Med. 2013;159:456-462.

Maciejewski ML, Hanlon JT. Underreporting Potentially Inappropriate Prescribing for Older Outpatients: Does It Matter? Ann Intern Med. 2013;159(7):496-497.