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112 Dual use of prescription insurance: drivers and challenges
  1. Anna Hung1,2,3,
  2. Abigail Shapiro1,
  3. Ellen B Lawrence1,
  4. Hollis J Weidenbacher1,
  5. Adrian D Brown1,
  6. Greeshma M Thomas1,
  7. Theodore S Berkowitz1,
  8. Shelby D Reed2,3,4,
  9. Valerie A Smith1,2,5,
  10. Jeffrey T Kullgren6,7,8,
  11. Angela Fagerlin9,10,
  12. Karen Steinhauser1,2,
  13. Carolyn T Thorpe11,12,
  14. Matthew L Maciejewski1,2,3
  1. 1Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, USA
  2. 2Department of Population Health Sciences, Duke University School of Medicine, Durham, USA
  3. 3Duke-Margolis Center for Health Policy, Durham, USA
  4. 4Duke Clinical Research Institute, Durham, USA
  5. 5Department of Medicine, Duke University School of Medicine, Durham, USA
  6. 6Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
  7. 7Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, USA
  8. 8Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA
  9. 9Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, USA
  10. 10Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences, Salt Lake City, USA
  11. 11Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, USA
  12. 12Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Chapel Hill, USA


Introduction Nearly 30% of Veterans with diabetes fill their medications through both VA and Medicare prescription drug insurance and have complicated choices about where to fill medications.1 The study objective was to understand drivers and challenges of filling through both systems and identify informational needs.

Methods We conducted semi-structured phone interviews with Veterans (n=24) and care partners (n=12), (e.g., family member, caregiver, or another involved in decisions about filling the Veteran’s prescriptions). The interview guide was developed based on the Ottawa Decision Support Framework.2 Interview transcripts were generated for thematic analysis.

Results Veteran interviewees were older than care partner interviewees (respective mean ages 77 and 69). Most Veterans were male (88%) and most care partners were female (92%). The main drivers for filling diabetes medications through two systems were cost and formulary availability; additional factors included distance and trust in providers and healthcare systems. Participants reported challenges such as high and variable copays, inability to switch all medications from one system to the other, and inconsistent care coordination between VA and Medicare providers.

Participants shared a preference to receive medications through one system and to be able to directly access information on expected medication costs and formulary availability through VA versus Medicare, as well as discuss this information with clinicians.

Discussion Despite a preference to use a single system to fill all medications, cost and formulary availability were the primary reasons for choosing to fill through both systems. Logistics, communication challenges, and information gaps impact dual use; Veterans and care partners may benefit from targeted information that allows them to make choices aligned with their values.

Conclusion Veterans and care partners have information gaps that lead to values-incongruent decisions on where Veterans fill their medications. Our next steps include creating a decision aid to help address this problem.


  1. Taber DJ, Ward R, Axon RN, Walker RJ, Egede LE, Gebregziabher M. Ann Pharmacother. 2019;53(7):675–682.

  2. Hoefel L, O’Connor A, Lewis KB, Boland L, Sikora L, Hu J, Stacey D. Medical Decision Making. 2020;40(5):555–81.

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