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Highlights of the Second Annual P&T Society Meeting: Trends in Managed Care Pharmacy

Speaker: Joseph Eichenholz, MA, Managing Director, Trigenesis Management Systems, Chatham, New Jersey.

Mr. Eichenholz outlined data in the Aventis Managed Care Digest Series to review managed care trends and their implications for the pharmacy. He noted that the major trends in health care were an increase in consumer power, a redefinition of the patient-physician relationship, an increasing sophistication of physician groups, a redefinition of relationships among stakeholders, changes in information and technology, a continued integration of “virtual” providers into organized delivery systems, and more aggressive employers and pharmacy benefit managers (PBMs).

The presentation reinforced Dr. Nash’s point that the underlying dynamics of health care were changing in part because of consumerism, and went on to say that the key to clinical and business success is benchmarking performance. The components of benchmarking will include demographics, the epidemiology of selected chronic diseases, clinical processes and outcomes, resource investment and results, and quality/satisfaction for consumers. Regarding consumerism, Mr. Eichenholz noted the effect of the “baby-boomer” population on the way in which health care is becoming more patient-centric. Mr. Eichenholz also discussed the history of HMOs and PPOs in terms of managing costs versus value, and how the future will probably require an integrated health care system.¬†cialis canadian pharmacy

How Does the P&T Committee Deal with the Rx to OTC Switch?

Speaker: Burton I. Orland, BS, RPh, Vice President of Pharmacy, Oxford Health Plans, Worchester, Massachusetts.

According to Mr. Orland, the main concerns of the P&T committee, in terms of prescription (Rx) drugs, are increased utilization/drug costs, mergers and acquisitions, combination therapies, legislative influence, DTC advertising, drug rider exclusions, and off-label uses. Mr. Orland noted that drug costs are increasing by 12% to 15% annually, or higher. Only 4% to 6% can be attributed to the pharmaceutical industry; other reasons are utilization and DTC advertising. The fewer companies that result from mergers, the less competitive the marketplace becomes. Combination therapies, which involve the use of three to four drugs in tandem (on average), are now being used to manage diseases such as HIV and diabetes. The influence of legislation on treatment problems like infertility affects coverage. Patients are influenced by DTC advertising to request certain drugs from their physicians. Costs are kept down by excluding certain drugs (e.g., contraceptives, cosmetics, and other so-called “lifestyle drugs”). There are 400 to 500 drugs in development, with dosing costs of $3 to $5. One remedy to these Rx drug problems is to switch drugs to an over-the-counter (OTC) status, which shifts the burden from the insurer to the consumer.

The Durham-Humphrey Amendment (1951), which established the Rx and OTC classes, allows the FDA to switch prescription drugs to OTC drugs under three scenarios: the manufacturer requests a switch by submitting a supplemental application to its approved new drug approval (NDA), the drug manufacturer petitions the FDA, or the drug is switched through an OTC drug review process, which is the most popular method. There have been successful switches (e.g., Gyne-Lotrimin, Tagamet, Axid, Dimetapp, Sudafed, Advil, Duo Film, Lotrimin, Benadryl, and Niacin). Some current drugs up for OTC consideration, Allegra, the morning-after pill, as well as some proton pump inhibitors and statins.

Smaller managed care organizations (MCOs), such as Fallon and Independent, are now covering OTC products within their formulary benefits. However, the larger HMOs (e.g., Cigna, Kaiser) are not. The criteria considered for covering OTC drugs include balancing the budget, reducing therapeutic category costs, minimizing out-of-pocket costs, balancing rebates versus the actual wholesale price (AWP) of OTCs, establishing co-pay differences, maximizing remaining rebates in the class, and avoiding higher cost drug choices.

Covering OTC drugs as a pharmacy benefit would lower drug costs, help track patient utilization, allow OTCs to be used as the first step in step therapy, and result in savings (compared to Rx drugs) for MCOs. For this to work, however, there needs to be physician buy-in. Incentives for physicians include reminding them that the costs are not out of pocket for them; providing them with prescription pads or stamps for convenience; demonstrating efficacy and safety profiles; and reimbursement. The ideal contract terms include “dollar one” rebates or market share, an NDC block on generic/competition, coverage for most sizes, customized “pull-through pieces” (drug information handouts), pharmaceutical company-educated MDs and network pharmacies, and product exclusivity (no generics). The PBM has to make sure that the generic will not be inadvertently dispensed; only the drug brand in the contract will. The various sizes (e.g., different pill amounts) should be covered. The customized pull-through pieces serve to ensure that the doctor is prescribing the drug correctly. The patient care and buy-in is facilitated by a lower co-pay, prepared patient information about the drug (making him/her better educated), and knowing that the physician is an advocate for the program, which represents the continuum of care. The member is motivated because there are fewer visits required, and patients can monitor themselves, so there is better compliance and reduced drug costs. There are some areas of concern, however, including inaccurate self-diagnosis, delays in treatment, sub-optimal dosing, and inappropriate drug use. Sub-optimal dosing results because OTCs are set at a lower dose than the Rx drugs. Working with the pharmaceutical industry to establish guidelines for patients, detailing physicians, being aware of over-utilizers of the drugs, and develop¬≠ing the aforementioned pull-through pieces can help avoid these problems. The PBMs have to be involved by messaging on-line to the network, adjucating claims correctly, tracking utilization, dispensing brand drugs only, and working with the pharmaceutical companies to provide drug information to the doctors and pharmacists and letting them know that the drug in question is covered by the MCO.

Even with PBM involvement, drug utilization can still go wrong. The physician might not explain the benefit to the patient; the patient might forget to get the benefit; there is an off-the-shelf mentality among some physicians and pharmacists (just picking up any drug to give to the patient); the patient can have problems with an OTC drug; the PBM might not send the message that the drug is covered; or the network inadvertently dispenses a generic. To make a switch work, the physician, patient, MCO, drug company, and PBM all have to work together.

Category: Health

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