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D A T A W A T C H
G E N E R I C - O N L Y  C O V E R A G E
W E B  E X C L U S I V E   

29 September 2004  
  

Effects Of Generic-Only 
Drug Coverage In A Medicare HMO

Was there any association between membership composition, costs,
and quality of care and the advent of a generic-only benefit in a
Medicare health maintenance organization?

By Jennifer Christian-Herman, Matthew Emons, and Dorothy George

ABSTRACT:

Rising pharmacy costs and demand for prescription drug coverage for broader populations of seniors have resulted in the implementation of generic-only pharmacy benefits in Medicare health maintenance organizations (HMOs). The impact on cost and quality of care is unknown. We examined data for members of a California Medicare HMO whose coverage changed to a generic-only benefit and found that the change was associated with reduced health plan pharmacy cost, increased out-of-pocket pharmacy costs for members, increased overall hospital admissions, changed drug-use patterns, and a negative impact on quality metrics for certain conditions. These findings have important implications for future research and health policy decisions.

Health spending in the United States is projected to increase to $3.4 trillion by 2013.¹ Although there are many cost drivers, prescription drug costs are one of the fastest-growing components. By 2013 these costs are expected to account for 15.5 percent of national health spending—nearly triple their percentage in 1993.²

Prescription drug coverage is an optional benefit offering for Medicare health maintenance organizations (HMOs), but many have traditionally offered this benefit to improve recruitment and retention of members. Rising drug costs have pressured Medicare HMOs to implement cost containment strategies, such as benefit limits and tiered formularies that shift costs to members. Cost pressures and public demand for coverage of prescription drugs, combined with the expanded range of medications having generic equivalents, have led a growing number of Medicare HMOs to cover generic medications only. Brand-name medications are available but paid for out of pocket by the patient (or through other secondary means arranged by the patient). In 2002, 26 percent of all Medicare HMOs covered generic medications only. This rate is nearly three times the rate of generic-only benefits in 2001, and it translates to 1.2 million Medicare HMO members with generic-only coverage.³ It has been estimated that more effective use of generic drugs could save beneficiaries $250 billion over the next decade.⁴

Despite the increased use of generic-only benefit designs, little is known about their impact on health care for the elderly. Because many Medicare beneficiaries choose their health plan based in part on its pharmacy benefit, the switch to a generic-only benefit could affect the membership composition of Medicare HMOs. Implementation of a generic-only formulary may attract healthier patients (“favorable selection”) or may result in sicker patients’ remaining in the plan because they have few other options (“adverse selection”). A generic-only benefit should reduce pharmacy costs to the health plan, but its association with out-of-pocket costs and other outcomes (such as clinical effects) are less clear. For many conditions, a generic-only benefit may not have a strong clinical effect if a sufficiently broad array of generic products is available to enable treatment standards to be met. Other conditions may require treatment with medications that do not have generic formulations. For these conditions, the generic-only benefit may reduce adherence to treatment guideline recommendations. Increases in out-of-pocket costs have been shown to reduce use of medications even in the chronically ill.⁵

We conducted this study to evaluate associations of a generic-only pharmacy benefit design with membership composition, drug spending by HMOs and their members, drug-use patterns, and adherence to treatment guideline recommendations (as a proxy for quality of care) for selected health conditions.

Study Data And Methods

The study assessed the associations between the switch to a generic-only pharmacy benefit and outcomes among members of a large Medicare HMO.⁶ Administrative data used for the study included enrollment information, facility claims, professional service claims, and outpatient prescription drug claims for more than 550,000 Medicare HMO members in California who were enrolled in 2001 or 2002, or both. Analyses included both a case group (changed to generic-only benefit) and a control group (continued brand-name and generic benefit). In 2001 the groups had similar prescription coverage for both brand-name and generic drugs. In 2002 the case group, which represented a mix of metropolitan and nonmetropolitan counties in California, switched to a generic-only prescription benefit with no coverage of brand-name drugs. The control group, which included two large metropolitan counties, continued with a benefit that covered a range of brand-name and generic drugs. We evaluated the effect of the benefit design change by comparing the change in endpoints for the groups from 2001 to 2002.

We also assessed potential clinical implications of the generic-only benefit by investigating hospital admission rates, drug-use patterns, and medication adherence. Adherence was defined in two ways: (1) Providers’ adherence to treatment guidelines was defined as the mean number of months with at least a one-day supply of medication recommended by evidence-based clinical guidelines; and (2) patients’ adherence to prescribed medications was the mean percentage of days for which the patient had a supply of medication. We addressed the associations with quality metrics for five clinical areas: congestive heart failure (CHF), coronary artery disease, diabetes, epilepsy, and depression (use of antidepressants). These areas were selected because their treatment may require the use of drugs from specific therapeutic classes for which generic options may be limited.

Study Results

Membership composition. The generic-only benefit group showed a sharp reduction in membership compared with the control group, but the change did not materially affect the overall demographic or clinical profile of the plan’s membership (Exhibit 1). The number of members in the case group fell by 32.2 percent between 2001 and 2002, compared with a decrease of 16.8 percent in the control group. Both groups experienced similar changes in members’ mean age and sex. There was no difference between groups in average patient severity as measured by the Charlson Comorbidity Index; this provides no evidence that the benefit resulted in attraction or retention of healthier or sicker patients.

Prescription drug spending. The change to a generic-only benefit lowered the health plan’s spending for prescription drugs (Exhibit 2). Costs to the health plan per member per month (PMPM) fell by $11 among cases (from $105 to $94) but increased by $2 among controls (from $108 to $110) (p < .0001).

The generic-only benefit design was associated with increased out-of-pocket prescription drug spending by members. Average PMPM out-of-pocket spending increased for case members by $16.60 between 2001 and 2002 (from $30.90 to $47.50) but only by $14.22 for control members (from $26.27 to $40.49) (p < .0001). Interestingly, enrollees’ payments for prescription drugs greatly increased (by approximately 50 percent) for both the case and control groups between 2001 and 2002, which indicates that factors such as other benefit structure changes (for example, copayment or maximum benefit amounts) and multifactorial and complex market trends (for example, more-restrictive formularies) may have affected the control group as well.

Prescription drug use. The generic-only benefit design was associated with a significant reduction in overall prescription drug use and in use of brand-name medications, and a significant increase in use of generic medications (Exhibit 3). The decrease in the number of prescriptions for the case group was significantly different than for the control group. Both the case and control groups increased their relative use of generic medications between 2001 and 2002, but the increase was larger among members with a generic-only benefit in 2002 (Exhibit 4). Thus, the change to a generic-only benefit was successful in altering drug-use patterns.

Overall hospital admission rates. Members who switched to a generic-only benefit design had a significantly increased likelihood of hospital admission in 2002 relative to controls (Exhibit 3). In 2002 the case group had an increase of 3.02 hospital admissions per thousand, while the control group had a decrease of 0.22 admissions per thousand.

Drug treatment for chronic conditions. We analyzed the associations between the change to a generic-only benefit and drug treatment patterns for four chronic health conditions (CHF, coronary artery disease, diabetes, and epilepsy) and one therapeutic drug class (antidepressants). For some of these clinical areas, generic medications were available for the major therapeutic classes recommended for management. For others, the availability was more limited: Either no generic formulations were available for key therapeutic classes, or only generic agents with less favorable safety, efficacy, or dosing profiles were available.

For each condition we describe potential clinical implications of a generic-only benefit and then present our results. Within the results, we comment on potential explanations for observed results when applicable.

Congestive heart failure. For CHF, the key clinical issue investigated was the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). An ACE inhibitor is recommended as a first-line drug in the treatment of CHF, particularly for patients with a decrease in cardiac output.⁷ The use of ACE inhibitors reduces mortality and improves quality of life in patients with CHF. Both brand-name and generic ACE inhibitors were available at the beginning of the study period, and an additional one (lisinopril) became generically available during 2002. Treatment guidelines do not differentiate between specific ACE inhibitors with respect to safety and efficacy. ARBs, which appear to have comparable efficacy, are typically used in patients who are unable to tolerate an ACE inhibitor. No generic ARBs are available.

The generic-only benefit had a small but negative association with the use of an ACE inhibitor or ARB among CHF patients. The mean number of months with an available supply of either type of drug fell between 2001 and 2002 for case patients but rose for control patients (Exhibit 3). ACE inhibitor use patterns changed markedly during the study period (Exhibit 5). The use of generic ACE inhibitors increased in both groups in 2002, but the rise occurred earlier and was more dramatic in the case group than in the control group. The use of brand-name ACE inhibitors dropped for both groups in mid-2002, an occurrence that may be related to the release of generic lisinopril.

We found no association between the generic-only benefit design and ARB use, despite the fact that no generic ARBs are available. A similar rate of ARB use (15 percent) was seen for both groups across the two years, which suggests that patients (who presumably are unable to tolerate an ACE inhibitor) are willing to pay out of pocket for these agents. Among those patients receiving either type of drug, the percentage of days with an available supply was high (approximately 90 percent) for both groups, which indicates that the benefit change did not negatively affect patient adherence. We found no association between the generic-only benefit and hospital admission rates in CHF patients.

Coronary artery disease. A critical treatment goal for patients with coronary artery disease is the control of low-density lipoprotein cholesterol (LDL-c) levels to reduce the risk of acute myocardial infarction (heart attack).⁸ A key aspect of treatment is the use of statins, a therapeutic class in which clinical differentiation exists among specific agents. In this therapeutic class, lovastatin, the sole generic agent, is not among the most potent with respect to reducing LDL-c levels.⁹ The lack of a generic formulation of the more potent statins may limit treatment options for patients who are unable to achieve adequate control of LDL-c with lovastatin or other generically available agents, such as fibrates, bile acid sequestrants, or nicotinic acid.

The generic-only benefit was associated with a decrease in statin use in members with coronary artery disease (Exhibit 6). In the case group, the mean number of months with an available statin supply fell between 2001 and 2002. By comparison, among the control group with the disease, the average number of months with an available statin supply remained almost the same between 2001 and 2002. It should be noted that the rate of statin use was low in both groups. The implementation of the generic-only benefit did not affect patient adherence.

Compared with the results for ACE inhibitors in CHF patients, there was a lower rate of conversion to a generic alternative for statins, with almost no generic statin use in the control group. A gradual increase in generic statin use was seen in the case group (from 0.8 percent in January 2002 to 7.7 percent in December 2002), although the overall rate remained low.

We found no relationship between the generic-only benefit and hospital admission rates for patients with coronary artery disease. However, because the use of statins is a long-term preventive intervention, an increase in acute coronary events such as heart attacks may not be expected within our time frame.

Diabetes. We examined three clinical metrics related to diabetes management: the use of glucose-lowering medications and the use of medications to reduce the risk of cardiovascular and renal complications of diabetes (statins and ACE inhibitors/ARBs). Along with nutritional therapy and exercise, insulin and oral glucose-lowering agents are instrumental in controlling blood glucose levels, which lowers the risk of many diabetes complications. Multiple agents with different modes of action may be required for optimal control of blood glucose in patients with Type 2 diabetes. All first-generation and most second-generation sulfonylureas are available in generic formulations. A generic formulation of metformin became available during the study year (2002), but metformin is not ideal for use in the elderly and has labeled contraindications for those with CHF or reduced kidney functioning.¹⁰ Other categories of oral hypoglycemic agents that may be needed to treat patients with Type 2 diabetes are not available in generic formulations. Depending on the formulary, a generic-only benefit may exclude coverage for some or even all insulin formulations.

Diabetic patients are at high risk for heart attack, and use of statins to control LDL-c levels is widely accepted.¹¹ The use of an ACE inhibitor or ARB is also recommended for many with diabetes, to protect kidney functioning.¹² The potential implications of a generic-only benefit related to ACE inhbitor/ARB and statin use are similar to the issues regarding CHF and coronary artery disease.

The generic-only benefit was associated with a significant decrease in the use of antidiabetic agents (Exhibit 3). Specifically, it was associated with a lower rate of use of insulin (p < .0001), insulin plus a single oral agent (p < .05), and the use of multiple oral agents (p < .0001). Patient adherence did not differ between the case and control groups.

The mean percentage of months with available oral diabetic supply was lower in the case group in 2002 (p < .0001). With regard to specific oral antidiabetic therapeutic classes, statistically significant reductions were observed in the case group for the use of insulin resistance reducers (such as thiazolidinediones or oligosaccharides,
p < 0001) and metformin (which was not generically available at the time of the switch, p < .0001). No difference was found in the use of sulfonylureas, alpha-glucosidase inhibitors, or meglitinides.

Enrollees with diabetes in the generic-only benefit group had a significant increase in the overall (diabetes- and non-diabetes-related) hospital admission rate per thousand
(p < .0001). The rate increased in the case group from 31.6 per thousand in 2001 to 33.3 per thousand in 2002, while it decreased for the control group from 31.7 to 29.7 per thousand over the same time period (p < .005).

The generic-only benefit was associated with a lower rate of ACE inhibitor or ARB use in members with diabetes (Exhibit 3). Similar to the medication use patterns described for CHF patients, the use of brand-name ACE inhibitors decreased and the use of generic ACE inhibitors increased for both case and control groups in 2002. The changes were earlier and more substantial for the case group. The rate of ARB use remained the same for the case group across both years (approximately 10 percent), despite the lack of a generically available agent.

As in the coronary artery disease population, the use of statins among patients with diabetes decreased dramatically for the case group in 2002 but remained constant for the control group. The difference between groups was statistically significant (Exhibit 3).

Epilepsy. Epilepsy is challenging to treat, particularly among the elderly, who may be at higher risk of adverse effects or drug interactions.¹³ Twenty to thirty percent of patients with epilepsy cannot achieve acceptable control of seizures without major adverse effects.¹⁴ Anti-epileptic drugs have varying efficacy with specific seizure subtypes and varying tolerability profiles. These drugs are typically classified as “conventional” or “newer” agents. Although there is no evidence indicating that newer agents are more effective, several studies have found that they may be better tolerated, have fewer drug interactions, and have a broader range of activity.¹⁵ Conventional agents are available generically, but newer ones are not. A generic-only benefit thus may limit treatment options for some patients whose seizures cannot be controlled with or who cannot tolerate conventional agents.
We measured the quality of epilepsy care using two metrics: use of any anti-epileptic drug and use of any “newer” anti-epileptic drug. No significant association was observed between the generic-only benefit design and the use of either any drug or any newer drug; however, the study population was relatively small (Exhibit 3).

Use of antidepressants. Although available antidepressant classes are generally considered equal in efficacy, selective serotonin reuptake inhibitors (SSRIs) may be preferred for initial therapy in the elderly because of their better tolerability and safety profiles. Fluoxetine (Prozac) is the only SSRI that is available in a generic formulation, but its long half-life can increase the risk of adverse events in seniors if it is taken daily.¹⁶ Other antidepressants include tricyclic antidepressants (TCAs), trazodone (Desyrel), bupropion (Wellbutrin), venlafaxine (Effexor), mirtazapine (Remeron), and nefazodone (Serzone). Although generic versions are available for virtually all TCAs, these agents tend to have a higher rate of adverse effects. Trazodone and bupropion are also available generically. The different mechanisms of action of antidepressants and the relatively common occurrence of adverse effects may necessitate the use of a specific agent or a combination of agents to achieve optimal control of depressive symptoms.

Antidepressant medication is a heavily used therapeutic class and can be prescribed for depression and for a number of other conditions. For this analysis, patients were identified based on use of antidepressant medication rather than a diagnosis of depression per se, because behavioral health diagnoses are often not accurately represented in administrative claims data. Although antidepressant medications can be prescribed for other clinical conditions (such as anxiety, chronic pain, and migraine prevention), drug-use patterns and adherence issues are important across these diagnostic categories as well. Antidepressant use was analyzed in the entire population of members rather than in the subset who were continuously enrolled.

The mean monthly percentage of members with an available antidepressant supply fell between 2001 and 2002 for the case group, while it increased in the control group during the same period. (Exhibit 7) The difference between the groups was statistically significant (Exhibit 3). Adherence to prescribed drug regimens did not differ between the groups.

We observed several changes in drug-use patterns. For these analyses, the antidepressants were grouped into four categories: SSRIs, TCAs, trazodone, and “other” agents (Effexor, Wellbutrin, Remeron, and Serzone). The generic-only benefit was associated with an overall decrease in the use of SSRIs as a class, a decrease in the use of brand-name SSRIs specifically, and an increase in the use of the generically available SSRI (fluoxetine). A similar pattern was seen for the “other” category. The case group had an overall decrease in the use of these agents but an increase in the use of the generic formulation of buproprion. The case group also had a significantly greater increase in the use of TCAs and trazodone. Thus, the generic-only benefit was associated with a lower rate of brand-name SSRIs, but with increased rates of generic fluoxetine (SSRI), generic bupropion, a TCA, or trazodone. Patients in the case group were less likely to be on any type of antidepressant medication at all.

Discussion And Conclusions

The generic-only pharmacy benefit design was associated with a reduction in plan membership but did not materially change membership composition or provide evidence of either favorable or adverse selection. The change to a generic-only benefit was associated with increased hospital admissions; however, the short-term duration of our study and other factors contributing to hospitalizations affect the interpretation of this finding. The change decreased the overall number of medications used and reduced the plan’s drug costs, but raised members’ out-of-pocket drug costs. These results suggest that the reduction in drug costs may have occurred at the expense of an increase in costs associated with other health care use—specifically, increased hospital admissions. Although the data we examined did not include inpatient costs, we attempted to evaluate the magnitude of the cost increase, using 2001 California-specific admissions data reported by the Henry J. Kaiser Family Foundation.¹⁷ If we estimate an average cost per admission of $8,736 (based on the number of admissions, average length-of-stay, and average per diem cost), the magnitude of the increased admission cost during the one-year horizon of this study was $2.36 PMPM, which is much lower than reported pharmacy savings ($13). However, the PMPM admission cost may underestimate the total impact, because it does not take into consideration indirect costs, custodial care, or the impact on health-related quality of life. Longer-term study is needed before conclusions can be made.

The decrease in plan pharmacy costs was not as large as might be expected. One reason may be that a change from an already tightly managed drug benefit to a generic-only formulary is a relatively small, “incremental” step. Greater cost savings could be realized if the benefit change were from a loosely managed to a generic-only benefit. A health plan’s contracting strategies also will affect the ultimate savings realized. However, in the climate of double-digit increases in pharmacy costs, even a 10 percent decrease is meaningful.

The study clearly demonstrated changes in drug-use patterns. The overall decrease in use (0.8 prescriptions PMPM), while seemingly small, is meaningful in a large health plan population. Of greater importance is the change in the composition of prescriptions. A higher rate of generic medications and a lower rate of brand-name medications were seen in both groups, which could reflect the release of generic formulations of several key drugs. However, the change was particularly noteworthy for the case group, which indicates that the switch to the generic-only benefit effectively altered drug-use patterns.

Across four of the five chronic conditions studied, our findings suggest a negative association between the generic-only benefit and selected measures reflecting adherence to treatment guidelines. There was no apparent association with patient adherence. Findings related to the therapeutic categories studied suggest that certain subgroups may be adversely affected by a generic-only benefit. The following findings imply potential quality-of-care issues that warrant further consideration.

Areas for further study. First, we found evidence of compromised use of ACE inhibitors in the treatment of coronary artery disease and diabetes despite the availability of generics and a dramatic change in use patterns. These agents have been demonstrated to improve clinical outcomes in both disease categories. Second, the generic-only benefit was associated with a dramatic decrease in the use of statins in both the coronary artery disease and diabetes populations. Statins for these patients have been proved to reduce the risk of heart attack, stroke, and death. An important issue may be the limited availability of generic statin options.

Third, we observed differences in use of oral glucose-lowering medications and insulin in the diabetes case group. Growing evidence suggests that a subset of patients with diabetes may benefit from the concomitant use of three or more glucose-lowering agents, which may require the use of brand-name-only agents.¹⁸ Of key concern is the higher rate of hospital admissions for the case group during the second year of the study. Fourth, the decrease in the overall use of antidepressants is of concern, because depression (the most prevalent indication for antidepressant use) is common and is often underdiagnosed and undertreated among the elderly. We observed changes in drug use: There was an overall decrease in SSRI use and an overall increase in TCA use, which may not be desirable from a patient safety perspective in the elderly.

Study limitations. These results are limited by several factors. We did not have the data to adjust for confounding factors that may have affected our results, including members’ socioeconomic characteristics, additional information about the HMO’s overall benefit design (for example, premiums, deductibles, copayments, and annual coverage limits), or information on competing benefit offerings from other Medicare HMOs in the same market. The clinical information necessary to assess the potential reasons behind therapeutic change or switching, as well as to assess the clinical outcomes (for example, LDL-c or blood glucose levels), were also not available in the claims data we studied. Because we did not have actual drug acquisition costs for the study, we used the average wholesale price (AWP) to calculate drug costs to the health plan. Typically, contracting enables a health plan to purchase both brand-name and generic drugs at costs well below the AWP. Although the actual savings to a specific health plan of switching to a generic-only formulary is thus dependent upon actual contract prices and the mix of brand-name versus generic drug use, the use of AWP in this study provides some measure of the relative magnitude of savings that could be achieved with such a benefit change. Finally, cost information for inpatient and outpatient claims was not available, which limits our ability to determine the association between pharmacy cost reductions and higher medical costs resulting from increased inpatient use. This is an important consideration in view of recent evidence that the use of newer medications is associated with lower nondrug medical spending and lower total medical costs.¹⁹

Our results may be affected by use of drugs outside the plan. Although there were incentives (such as discounts) for members to fill noncovered prescriptions through contracted pharmacy providers, some of the case group may have obtained prescriptions for brand-name drugs from sources outside the health plan. Our study would not have captured complete usage for members who obtained medications through physician samples or patient assistance programs or for prescriptions filled in noncontracted pharmacies and paid for out of pocket. Although the groups did not differ significantly in overall demographic or clinical profiles, slight differences could have contributed to the differences observed in outcome variables. Observed baseline differences in use suggest some inherent variation in drug-use patterns between the groups. A final limitation is the lack of data prior to 2001 or after 2002. First-quarter 2001 rates in some analyses appeared particularly low, in part because of incomplete data for prescriptions filled at the end of 2000, especially as some may have been filled for three months through the mail-order benefit. Additionally, some trends observed at the end of 2002 might be better understood if data into 2003 were available.

Policy implications. The study demonstrated that switching to a generic-only benefit changed drug-use patterns and lowered total pharmacy costs for the Medicare HMO population studied. However, evidence suggesting a negative effect on quality of care was noted overall and across four clinical areas (CHF, coronary artery disease, diabetes, and antidepressant medication use). These results warrant further study, with other measures of quality of care and, ideally, using databases and methodologies to directly evaluate the clinical impact of changes in drug use patterns. Pharmacy cost savings may be eroded by increased total medical costs for these members, especially in light of increased hospital admissions.

The potential implications of these findings must be considered by health policy decisionmakers as they extend beyond Medicare HMOs to include commercial carriers, Medicaid, and traditional Medicare, all of which are facing similar financial constraints. Given the mixed findings, it appears that a generic-only benefit may not be an optimal solution at this time. As additional therapeutic options become available (that is, new medications or availability of new generics), the impact of a generic-only benefit design must be continually reassessed. A greater understanding of the specific clinical and economic outcomes of such a benefit design will help identify opportunities for refinement of the benefit or other innovative solutions.

This study was supported by a grant from the California HealthCare Foundation. The authors acknowledge the involvement of Constella Health Strategies, particularly Merle Haberman, Mary Patton, Ruby Vendiola, and Pam Kadlubek.

NOTES

1. S. Heffler et al., “Health Spending Projections through 2013,” 11 February 2004, Health Affairs, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.79 (14 September 2004).
2. Ibid.
3. Centers for Medicare and Medicaid Services, “M+C Changes in Access, Benefits, and Premiums, 2001 to 2002,” cms.hhs.gov/healthplans/trends/mplusc_changes.pdf (31 August 2004).
4. G. Ritter, C.P. Thomas, and S.S. Wallack, “Greater Use of Generics: A Prescription for Drug Cost Savings” (Waltham, Mass.: Institute for Health Policy, Brandeis University, 2001).
5. D.P. Goldman et al., “Pharmacy Benefits and the Use of Drugs by the Chronically Ill,” Journal of the American Medical Association 291, no. 19 (2004): 2344–2350.
6. A more detailed description of the study methods is available online at content.healthaffairs.org/cgi/content/full/hlthaff.w4.455/DC1.
7. American College of Cardiology/American Heart Association Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure, “ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: A Report of The American College of Cardiology/American Heart Association Task Force on Practice Guidelines,” 2001, www.acc.org/clinical/guidelines/failure/hf_index.htm (31 August 2004).
8. National Cholesterol Education Program, “Third Report of the Expert Panel on the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), Final Report,” Pub. no. 02-5215 (Bethesda, Md.: National Heart, Lung, and Blood Institute, 2002).
9. E.J. Schaefer et al., “Comparisons of Effects of Statins (Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, and Simvastatin) on Fasting and Postprandial Lipoproteins in Patients with Coronary Heart Disease Versus Control Subjects,” American Journal of Cardiology 93, no. 1 (2004): 31–39.
10. Bristol-Myers Squibb, glucophage product insert, www.glucophagexr.com (14 September 2004).
11. American Diabetes Association, “Management of Dyslipidemia in Adults with Diabetes,” Diabetes Care 26, Supp. 1 (2003): S83–S86.
12. ADA, “Nephropathy in Diabetes,” Diabetes Care 27, Supp. 1 (2004): S79–S83.
13. S.M. LaRoche and S.L. Helmers, “The New Antiepileptic Drugs: Scientific Review,” Journal of the American Medical Association 291, no. 5 (2004): 605–614.
14. R.H. Mattson, “Efficacy and Adverse Effects of Established and New Antiepileptic Drugs,” Epilepsia 36, Supp. 2 (1995): S13–S26.
15. LaRoche and Helmers, “The New Antiepileptic Drugs.”
16. D.M. Fick et al., “Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults,” Archives of Internal Medicine 163, no. 22 (2003): 2716–2724.
17. Henry J. Kaiser Family Foundation, “State Health Facts Online: California,” www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=profile&area=California (29 July 2004).
18. A.J. Scheen, “Clinical Efficacy of Acarbose in Diabetes Mellitus: A Critical Review of Controlled Trials,” Diabetes Metabolism 24, no. 4 (1998): 311–320.
19. F.R. Lichtenberg, “Are the Benefits of Newer Drugs Worth Their Cost? Evidence from the 1996 MEPS,” Health Affairs 20, no. 5 (2001): 241–251.

Jennifer Christian-Herman (jennifer.christian-herman{at}cerner.com) is associate director, Health Services Research, at Cerner Health Insights in Beverly Hills, California. Matthew Emons is a principal investigator there, and Dorothy George, senior associate director.

DOI: 10.1377/hlthaff.w4.455
©2004 Project HOPE–The People-to-People Health Foundation, Inc.