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Utilization management policies are pervasive in the Medicare Part D program. We assess the effect of utilization management restrictions in the Medicare Part D program on the quality of care in two clinical areas – community-acquired pneumonia (CAP) and urinary tract infections (UTI). In this study, we identified new cases of CAP and UTI from Medicare claims data from 2010 to 2016. We assessed the relationship between exposure to utilization management for antibiotic medications suitable for treating these conditions and adverse health outcomes, based on the Agency for Healthcare Research and Quality prevention quality indicators. We identified 147,526 cases of CAP and 632,407 UTI cases in our data. In these samples, the adverse event rate varied from 3.6 to 5.7%. The probability of an adverse event increased by 0.75 (p = 0.061) percentage points for each ten percentage point increase in exposure to quantity limits (one form of utilization management) among people with CAP. There was no relationship between utilization management and adverse events in the UTI cohort. In some circumstances, exposure to utilization management policies–particularly quantity limits–may adversely affect health.

Effects of utilization management on health outcomes: evidence from urinary tract infections and community-acquired pneumonia