title: Factors associated with choice of pharmacy setting among DoD health care beneficiaries aged 65 years or older.
abstract: BACKGROUND
  Department of Defense (DoD) health care planners want to stimulate a voluntary migration of prescription fills from military and community pharmacies to its mail-order pharmacy, a lower-cost dispensing option for the department. Beneficiary cost share for a 90-day supply of generic/ brand medication is $0/$0 at military (DoD) pharmacies, $3/$9 at the DoD mail-order pharmacy, and $9/$27 at network community pharmacies.
  
  
  OBJECTIVE
  To examine the pharmacy use patterns among the beneficiary population age 65 years or older, traditionally the heaviest users of the TRICARE DOD prescription drug benefit, to identify factors that are associated with beneficiary use of pharmacy setting(s).
  
  
  METHODS
  Outpatient prescription fill records were examined for TRICARE beneficiaries age 65 years or older (N = 300,084) residing in North Carolina, Texas, and California for dates of service from December 1, 2004 through February 28, 2005. Binary logistic regression models were run for each type (military, community, and mail order) and number of pharmacy settings used by beneficiary gender, age group, catchment area status (located either within or outside a 40-mile radius of each military pharmacy), state, and number of medications obtained (defined as count of unique combinations of strength, and route of administration). The mean number of medications per beneficiary and cost per medication were tabulated for each type and number of settings used.
  
  
  RESULTS
  In the 3-month period from December 1, 2004 through February 28, 2005, beneficiary use of military, community, and mail-order pharmacies was 45.4%, 67.6%, and 22.1%, respectively. About 67% of the study population used 1 setting exclusively and 2.4% used all 3 settings. Noncatchment residents were significantly less likely (adjusted odds ratio [AOR]= 0.080; 95% confidence interval [CI], 0.078-0.082) to use a military pharmacy exclusively and significantly more likely to use a community pharmacy (AOR = 4.64; 95% CI, 4.55-4.73) or the mail-order pharmacy (AOR = 3.92; 95% CI, 3.80-4.05) exclusively than were catchment residents. Beneficiaries taking 10 or more medications were more likely (AOR = 8.43; 95% CI, 8.21-8.65) to use multiple settings than were those who obtained 3 or fewer medications. Single-setting users obtained a median of 4 (interquartile range [IQ]) 2-7) medications with a median copayment of $7.00 (IQ $0-$13.19) per medication. Those who used all 3 settings obtained a median of 9 (IQ 7-12) medications with a median copayment of $4.33 (IQ $3.00-$6.00) per medication. Among beneficiaries who obtained 6 or more unique medications during the 90-day study period, approximately 25% used the mail-order pharmacy to obtain 1 or more prescription fills.
  
  
  CONCLUSIONS
  A significant portion of the study population did not use the mail-order pharmacy despite the financial incentive to use mail-order rather than community pharmacies. Relatively small financial incentives alone may be inadequate for promoting a switch to the mail-order option among those beneficiaries not already using it in a pharmacy benefit plan with low copayments. Larger monetary and other incentives may be necessary to achieve the desired transfer of prescriptions fills to the mail-order pharmacy and the associated reduction in military pharmacy workload.
authors.affiliation: Office of Assistant Secretary of Defense, Health Affairs, TRICARE Management Activity, Health Programs Analysis and Evaluation, 5111 Leesburg Pike, Suite 810, Falls Church, VA 22041, USA. andrea.linton.ctr@tma.osd.mil
authors.forename: Andrea
authors.initials: A
authors.lastname: Linton
authors.forename: Mathew
authors.initials: M
authors.lastname: Garber
authors.forename: Nancy K
authors.initials: NK
authors.lastname: Fagan
authors.forename: Michael
authors.initials: M
authors.lastname: Peterson
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002391:Catchment Area, Health / Q000706:statistics & numerical data; D002755:Choice Behavior; D003365:Costs and Cost Analysis; D017723:Drug Utilization Review / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D006264:Health Benefit Plans, Employee / Q000458:organization & administration / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008329:Managed Care Programs / Q000706:statistics & numerical data; D016017:Odds Ratio; D010349:Patient Compliance / Q000706:statistics & numerical data; D010593:Pharmaceutical Services / Q000706:statistics & numerical data; D011177:Postal Service / Q000706:statistics & numerical data; D012044:Regression Analysis; D012737:Sex Factors; D013997:Time Factors; D014481:United States; D037041:United States Government Agencies / Q000458:organization & administration / Q000706:statistics & numerical data*