Prescription Benefit Plans Research Articles

Positive Medication Changes Resulting from Comprehensive and Noncomprehensive Medication Reviews in a Medicare Part D Population.

Health care organizations face the challenge of reducing costs while improving health outcomes. Currently, more than 39 million seniors are enrolled in a Medicare Part D prescription benefit plan, many of whom also qualify for medication therapy management (MTM) services. MTM programs provide valuable services designed to prevent or resolve medication-related problems (MRPs). Two core components of all MTM programs include comprehensive medication reviews (CMRs) with followup interventions and focused non-CMR interventions. Currently, there is limited research comparing the rate of MRPs resolved by CMR and non-CMR interventions. To determine whether CMRs versus non-CMR interventions resulted in more pharmacist-initiated intervention recommendations and positive medication changes. This retrospective, cross-sectional quality improvement project evaluated outcomes for individuals who received interventions following a CMR compared with those who received non-CMR interventions as part of a comprehensive MTM program. For this project, eligible individuals qualified for an MTM program. A positive medication change was defined as the addition of an appropriate medication or the removal of an inappropriate medication within 120 days of a pharmacist recommendation. Differences between the groups were calculated using the Wilcoxon rank sum test. During the 2-year period (2012 and 2013), 788,756 beneficiaries were enrolled in the MTM program and evaluated for potential MRPs. In both years, pharmacists recommended more medication changes per member for those receiving a CMR (0.81 in 2012 and 0.82 in 2013) compared with the non-CMR group (0.68 in 2012 and 0.61 in 2013; P value < 0.001 for both years). However, recommendations made via non-CMR interventions (representing the vast majority of all medication reviews) were more likely to result in a positive medication change (OR = 1.24, 95% CI = 1.21-1.28 for 2012; OR = 1.26, 95% CI = 1.22-1.30 for 2013). These quality improvement project results suggest that Medicare Part D beneficiaries participating in a university-based MTM program who received non-CMR interventions had a higher likelihood of having positive medication changes than those receiving CMRs. These results are enlightening and may provide initial evidence to support inclusion of a non-CMR performance metric for the Centers for Medicare & Medicaid Service's star ratings for MTM programs. No outside funding supported this study. The University of Arizona Medication Management Center (UAMMC)/SinfoniaRx provides grant funding to the University of Arizona for research. Augustine reports support from the UAMMC and ownership of Pfizer stock and was a graduate student at the University of Arizona College of Pharmacy at the time of this study. The authors report no other potential conflicts of interest. Buhl and Augustine contributed study concept and design, collected the data, and wrote the manuscript. Data interpretation was performed by all the authors. Taylor, Warholak, Augustine, and Martin revised the manuscript.

Attitudes of Medicare-eligible Americans toward mail service pharmacy.

For many years, community pharmacies provided mail delivery as a convenience for a small segment of special circumstance patients who requested it. Fueled by a movement among plan sponsors and prescription benefit managers to encourage or require its use, growth in mail service pharmacy began to accelerate in the 1980s and now accounts for nearly 25% of the market in the general population and a much higher percentage of seniors. To assess the attitudes of Medicare-eligible Americans toward concerns that have been raised about mail service pharmacy and its mandated use in the prescription benefit plans of public and private insurance programs. Existing published literature was reviewed, and interviews were conducted with Medicare-eligible persons aged 65 and older to identify potential areas of concern with mail order pharmacy services. A survey was constructed and mailed to a nationally representative random sample of 6,500 persons between the ages of 65 and 79 in July 2012. By the cutoff date, 669 completed surveys had been received, and an additional 221 had been returned as undeliverable, resulting in an overall response rate of 10.7%. Nearly half of respondents listed chain pharmacy as their primary source of prescription medications (47.7%) followed by mail service (34.1%), independent pharmacy (13.1%), and other (5.1%). Responses of seniors residing in rural zip codes compared with those in nonrural zip codes demonstrated significantly higher agreement with several concerns, including lost or stolen medications, receiving the exact medication the physician prescribed, and the effects of exposure to heat, cold, or moisture. Two additional concerns approached statistical significance: the ability to speak with a pharmacist face-to-face and the ability to obtain medications quickly if needed. A total of 533 (83.7%) indicated they would oppose mandated mail order in their current benefit plan if it would cause the local community pharmacy they rely on for immediate medication needs to close. The mean risk of such an eventuality that respondents were willing to accept was 42.2%, indicating they would oppose mandatory mail order if there were greater than about a 4-in-10 chance it would cause the loss of their local pharmacy. Seniors appear to be practical and pragmatic about the sources of their prescription medications. While most see a role for mail service pharmacy, they are also aware of its limitations. Many have needs they believe cannot be adequately met by mail service or have relationships with local pharmacies and pharmacists they believe are important for maintaining their health and well-being. As a result, seniors are relatively risk averse when it comes to the loss of their local community pharmacy, even if they routinely use mail order for most of their medications. Beyond their specific concerns, most seniors oppose any restrictions on their freedom to use the pharmacy of their choice on general principle.

Cardiovascular Pharmacogenomics: Current Status and Future Directions—Report of a National Heart, Lung, and Blood Institute Working Group

The National Heart, Lung, and Blood Institute (NHLBI) convened a Working Group on January 7, 2011, at George Washington University in Washington, DC, to provide recommendations to the NHLBI that would guide informed decisions on research directions and priorities in the field of cardiovascular

A comparison of mail-service and retail community pharmacy claims in 5 prescription benefit plans

Background Little evidence has been presented to date that would either support or refute a widely held belief that mail-service pharmacy utilization routinely produces savings in drug benefit costs for prescription benefit plan sponsors. Objective To present a comparative analysis of mail-service and community pharmacy service drug benefit costs for 5 employer-sponsored prescription drug benefit plans. Methods A cross-sectional comparison of 17,725 matched transaction pairs of community and mail-service prescriptions from a data set comprised 484,987 prescription claims from a convenience sample of 5 employer-sponsored prescription benefit plans. Differences between community pharmacy and mail-service prescription transactions were examined at the per-unit level of analysis for drug ingredient costs, dispensing fees, co-payments, dollar amounts paid by plan sponsor, and total dollar amounts. Results Overall, the total cost of prescriptions was lower through mail-service pharmacies for all 5 plans studied. Two of 5 plans had co-payment incentives to use mail-service, yet plan sponsors paid more for mail-service drugs; respectively, 4.5% and 8.3% more overall, 25.0% and 21.4% more for generic medications; and 3.0% and 7.0% more for brand name medications. Mail-service co-payments were 48.9% and 51.7% lower. Mail-service utilization rates were 15.2% and 31.5% of the total number of prescriptions dispensed in the period studied. Three of 5 plans had no co-payment incentive to use mail-service and paid less for mail-service drugs; respectively, 18.7%, 6.6%, and 15.7% less overall; 17.4%, 15.6%, and 7.9% less for generic medications; and 18.8%, 5.2%, and 16.6% less for brand name medications. Mail-service co-payments were 10.5% more, 5.2% less, and 1.8% more than community pharmacy co-payments, respectively. Mail-service utilization rates were 0.8%, 1.2%, and 4.4%. Conclusion Co-payment incentives to use mail-service pharmacies instead of community pharmacies were associated with higher mail-service utilization rates and with higher costs to plan sponsors. Absence of a co-payment incentive to use mail-service pharmacies was associated with lower mail-service utilization rates and with lower costs to plan sponsors.

Pilot study of a hierarchical Bayes method for utility estimation in a choice-based conjoint analysis of prescription benefit plans including medication therapy management services

Background Consumers face an array of multiattribute prescription benefit insurance programs that include different access points (retail, supermarket, Internet, etc) and levels of pharmacist interaction (including medication therapy management services [MTMSs]). Because of this, there is a need for more sophisticated information to drive prescription benefit plan design. Objectives A pilot study to determine if choice-based conjoint (CBC) analysis with hierarchical Bayes (HB) estimation for individual level part-worths could provide a stable model for attribute preferences for prescription benefit insurance; to pilot test the addition of MTMSs to a prescription benefit management model; and to pilot and compare logit-based utility estimates to HB estimations in a conjoint market simulator. Methods A mail-based survey was conducted using a random sample of 1500 residents of the United States. A CBC analysis instrument was developed to provide a single-stated choice from a selection of different prescription benefit plans. Choice tasks were varied based on the attributes: co-payment, pharmacy access, formulary, level of pharmacist interaction including MTMSs and monthly premium. Analysis included logit-based and HB estimation for utilities, and preference share market simulation testing. Results The utility estimations from HB analysis were consistent with those seen in the logit-based analysis. A goodness of fit of 83% (root likelihood) was achieved in the HB utility estimations with only 4 choice tasks per respondents and the inclusion of MTM-like services. There was convergence on preference shares from the market simulation between the 2 estimation methods. Conclusions The use of CBC analysis with HB estimation provided utilities similar to those estimated using aggregated logit-based methods, with the added benefit of respondent specific part-worth scores for each attribute level. A larger sample, changes in the instrument design, more panels (tasks) per respondent, and selection of conjoint methods may allow for more predictive information from market simulators.

Undocumented source of pharmacy benefit manager revenue

The difference between what pharmacy benefit management companies (PBMs) charge prescription benefit plan sponsors and what dispensing pharmacies are paid ("spread") was studied. Data from prescription transaction invoices from two large employer groups, each using a different PBM, and 84 community pharmacies (which differed for each employer group due to clear geographic separation) participating in these plans between October 1, 2002, and December 31, 2004, were studied. Detailed community pharmacy payment transaction records were compared with PBM claim records from two employers. One employer provided 49,633 prescription claim records, and the other employer provided 120,684 prescription claim records. Spread between amount due billed to the employer by the PBM and amount due paid to the dispensing pharmacy by the PBM for all prescriptions, for brand-name prescriptions, and for generic prescriptions was analyzed. For the two PBMs combined, the mean +/- S.D. spread for 20,376 paid transactions was $1.82 +/- $8.26 per prescription. The mean +/- S.D. spread for brand-name prescriptions was $0.07 +/- $5.18 and for generic medications was $4.20 +/- $10.69 per prescription. The two PBMs differed significantly in their spread for all drugs ($2.30 +/- $6.17 and $1.78 +/- $8.40) and for brand-name drugs ($0.47 +/- $3.21 and $0.04 +/- $5.30). The difference between PBMs for spreads on generic medications did not achieve statistical significance. Wide variations in spread pricing existed between two PBMs and between brand-name and generic medications. Pharmacists and prescription benefit plan sponsors should be aware of this discrepancy and seek a more transparent contract with PBMs.

Letters

Back to table of contents Previous article Next article LettersFull AccessLettersJennifer M. Park M.D.Ravi Hariprasad M.D.Lawrence T. Park M.D.Jennifer M. Park M.D.Search for more papers by this authorRavi Hariprasad M.D.Search for more papers by this authorLawrence T. Park M.D.Search for more papers by this authorPublished Online:1 May 2006https://doi.org/10.1176/ps.2006.57.5.722aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Medicare Part D and DecompensationTo the Editor: We recently evaluated a woman in the emergency department who was disabled by recurrent major depression. One month before her visit, she became extremely distressed and hopeless when she received a brochure outlining the Medicare Part D program and became overwhelmed by the complexity of the possible prescription benefit plans. This hopelessness led her to abruptly discontinue her ten medications for depression and cardiac disease, and she attempted suicide by overdose one week later. Caring for this patient prompted us to compare the Medicare Part D prescription plans ourselves. A Medicare Web site ( 1 ) listed the 18 companies that offer a total of 44 different plans in Massachusetts—a daunting list. We called the customer service number for each company to request a Web site that would provide a drug formulary. Two offices left us on hold indefinitely, two were not open, two provided us with incorrect Web site information, and two did not have formularies accessible online at that time. Of the ten companies' formularies that were online, only one explained the cost of prescription drugs for Medicaid recipients. We searched the formularies for the ten medications used by the patient, using generic and brand names as written in her medication list. Of the various plans, one offered all ten of her medications on its formulary; most offered from four to nine of them. In many cases, it was impossible to know the monthly cost of this list of drugs because of varying premiums, deductibles, copayments, and limits. Among patients with mental illness, anticipation of changes in treatment providers or treatment plans can have a destabilizing effect. This case demonstrates the potential for psychiatrically and medically compromised patients to decompensate as they are faced with a complicated array of coverage options. Given 44 possible plans, each with relative advantages and disadvantages, covered and noncovered medications, and varying copayment options, it is understandable that individuals will experience stress over making such a decision. This stress is likely to be compounded when such a decision is made in the context of life-threatening illness, financial hardship, financial penalties for not choosing a plan in a timely fashion, and the possibility that a single plan will vary its formulary over time ( 2 ). In addition, considering the difficulty we faced as we researched the formularies over several hours, we wonder how physicians will obtain these lists when necessary. Educating ourselves and our patients and maintaining their optimal treatment as they enroll in the Medicare Part D program will be an important and extremely challenging task.Dr. Jennifer Park is director of the acute psychiatry service and Dr. Lawrence Park is director of psychiatric inpatient services at Massachusetts General Hospital (MGH) in Boston. Dr. Hariprasad is a resident in the MGH and McLean Hospital residency program.

Poor Short-Term Survival and Low Use of Cardiovascular Medications in Elderly Dialysis Patients After Acute Myocardial Infarction

Beta-blockers, statins, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) are standard therapies after myocardial infarction (MI) in the general population. Their use and association with mortality in elderly dialysis patients after MI have not been studied sufficiently. Claims records from Medicare and Medicaid patients aged 65 years and older who participated in prescription benefit plans of 2 eastern states were used to identify dialysis patients with MI between 1995 and 2003. Study outcomes were outpatient use of beta-blockers, statins, and ACE inhibitors and/or ARBs within 90 days after MI. We used multivariate logistic regression to assess predictors of such use. Multivariate Cox regression was applied to test for associations between beta-blocker, statin, and ACE-inhibitor and/or ARB use and 1-year mortality. We identified 902 dialysis patients who were hospitalized with MI. Of these, 39.5% died within 90 days and 63.6% died within 1 year after MI. Of 494 patients who were discharged within 21 days or less and survived longer than 90 days, 31.0% were administered an ACE inhibitor and/or ARB; 19.4%, a statin; and 34.2%, a beta-blocker after discharge. Use of ACE inhibitors and/or ARBs was associated with a 30% reduction in 1-year mortality (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.50 to 0.98), whereas statin (HR, 0.97; 95% CI, 0.65 to 1.45) and beta-blocker use (HR, 1.05; 95% CI, 0.78 to 1.43) were not. Elderly dialysis patients have excessively high mortality and low use of standard therapies after MI. Only ACE inhibitors and/or ARBs were associated with a reduced risk for death at 1 year in this population. Whether the high mortality rate in this population is attributable to such low use of preventive cardiovascular medications remains uncertain.

Prescription Drug Spending for Medicare+Choice Beneficiaries in the Last Year of Life

In 2006, Medicare implemented its prescription benefit plan. Therefore, insights into medication costs at the end of life may help guide clinicians to navigate Medicare Part D coverage for chronically ill individuals. We examined drug spending by disease and demographics for Medicare+Choice (M+C) beneficiaries in the last year of life (LYOL). Retrospective review of M+C decedents' drug claims and enrollment data collected between January 1998 and December 2000, supplemented by the Medicare denominator file and 1990 Census data. Four thousand six hundred two beneficiaries in a large national managed care organization. We analyzed the relationship between prescription drug expenditures and sociodemographic descriptors, insurance characteristics, and cause of death. The mean annual number of prescriptions filled was 36.9; the managed care organization (MCO) paid $539 and beneficiaries paid $627. Higher expenditures were significantly correlated with female gender, higher number of comorbidities, and whether beneficiaries obtained the insurance as an employer-based retiree benefit. Minority beneficiaries had 26% fewer prescriptions. Increasing levels of annual median household income corresponded with a 20% increase in the number of prescriptions and a 25% increase in mean out-of-pocket expenses, between those with a median household income of less than $20,000 and those with $40,000 or greater. In the LYOL, chronic obstructive pulmonary disease and diabetes had the highest average number of prescriptions and total expenditures. Individuals dying from strokes or other unclassifiable conditions had the lowest average number of prescriptions and average total expenditures. Medication expenditures in the LYOL were highly dependent upon selected sociodemographic, insurance characteristics, and disease states.

Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost

The objective of this study was to evaluate the impact of medication adherence on healthcare utilization and cost for 4 chronic conditions that are major drivers of drug spending: diabetes, hypertension, hypercholesterolemia, and congestive heart failure. The authors conducted a retrospective cohort observation of patients who were continuously enrolled in medical and prescription benefit plans from June 1997 through May 1999. Patients were identified for disease-specific analysis based on claims for outpatient, emergency room, or inpatient services during the first 12 months of the study. Using an integrated analysis of administrative claims data, medical and drug utilization were measured during the 12-month period after patient identification. Medication adherence was defined by days' supply of maintenance medications for each condition. The study consisted of a population-based sample of 137,277 patients under age 65. Disease-related and all-cause medical costs, drug costs, and hospitalization risk were measured. Using regression analysis, these measures were modeled at varying levels of medication adherence. For diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs. For these conditions, higher medication costs were more than offset by medical cost reductions, producing a net reduction in overall healthcare costs. For diabetes, hypercholesterolemia, and hypertension, cost offsets were observed for all-cause medical costs at high levels of medication adherence. For all 4 conditions, hospitalization rates were significantly lower for patients with high medication adherence. For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy.

The Importance of Medication Adherence in Improving Chronic-Disease Related Outcomes

in chronic conditions is a recognized public health problem. Rates of nonadherence with any medication treatment may vary from 15% to 93%, with an average estimated rate of 50%. 3 The association among increased medication adherence, improved health outcomes, and lower healthcare costs is well known. 4 Many factors may influence patients’ adherence to the medication intervention: patients’ demographics, cost of medications, number of medications taken by the patient, nature of the medical intervention, and nature of the medical condition. 5,6 Healthcare costs have shown to vastly differ among patients with high and low adherence, with a clear relationship seen between increased medication adherence and lower healthcare costs. 7 Patients’ failure to adhere to the medication regimen may cost as much as $300 billion to the healthcare systems in the United States. 8 In this issue of Medical Care, Sokol and colleagues present the findings of a retrospective cohort study of 137,277 patients enrolled in medical and prescription benefit plans, in which they examine the relationship between medication adherence and healthcare utilization and costs for 4 chronic conditions: diabetes, hypertension, hypercholesterolemia, and congestive heart failure. This research represents an important milestone in our understanding of the role of medication adherence in chronic diseases. 9 Not only does this research show that higher medication adherence is associated with lower avoidable healthcare utilization and morbidity across many chronic conditions, it establishes the role of increased medication utilization and adherence in the effective management of the chronic disease condition. Medication nonadherence with medication regimens is a well-recognized, but understudied, public health problem. 1– 8 This effort by Sokol and colleagues represents one of the first times the ramifications of medication nonadherence in affecting patient morbidity are studied and compared across 4 prevalent chronic medical conditions using large patient samples. The next steps after establishing the clear associative relationship between medication nonadherence and poor patient outcomes should be: 1) to confirm these strong associative relationships as being causal by using

Judgment processes in older adults' drug benefit evaluations

Background The Medicare Prescription Drug, Improvement and Modernization Act of 2003 will provide drug coverage to older adults through a variety of mechanisms, including stand-alone prescription drug benefits. Variation in cost-sharing and utilization controls is permitted, leading potentially to a wide variety of prescription benefit plans. However, little is known regarding the manner in which beneficiaries will integrate information to form plan evaluations. Objectives The objectives of this study were to assess and compare the use of compensatory and configural judgment models in older adults' evaluations of drug benefit plans. Methods Three focus groups were conducted with a total of 19 seniors to elicit relevant drug plan attributes. A separate group of 32 seniors then judged the suitability of 48 drug benefit profiles based on these attributes. Within-subjects regression analysis was used to reveal each participant's judgment policy. Results Focus groups suggested that copayment, premium, deductible, formulary use, and mail-service use were relevant plan attributes. Regression analyses showed that while most participants used compensatory judgment models in evaluation formation, 12 (37.5%) subjects used conjunctive judgment models. Conclusions Configural judgment processes are used frequently by older adults when evaluating drug benefit plans. Future research using more fine-grained techniques (eg, process tracing) might help further elucidate judgment processes in this context.

Improvements in Asthma Pharmacotherapy and Self-Management

In day-to-day practice, asthma treatment and self-management often fall short of the objectives defined by clinical practice guidelines. The objective of this study was to determine whether a population-based asthma disease management program, using broad-based educational interventions, can have a favorable impact on physician and patient adherence to guidelines-based care. A longitudinal, before-and-after design was used to evaluate program impacts on pharmacotherapy and health status. Patients with asthma (n = 35 450) were enrolled in the program from September 2000 through to June 2001. Patients were identified for the study based on a 12-month retrospective analysis of pharmacy claims. Patients were members of prescription benefit plans managed by Medco Health and were aged 5 years and older. Patients in the intervention group received asthma education materials during the 12-month period following enrollment. The materials emphasized guidelines-based principles of asthma pharmacotherapy, self-management, trigger avoidance and patient-physician partnership. Physicians received guidelines-based flow sheets to facilitate therapy tracking, and pharmacotherapy review. Asthma drug utilization was measured during the 12-month period prior to enrollment and the 12-month period following enrollment. Utilization data on controller and reliever medications were derived from a pharmacy claims database. Drug utilization changes for the intervention group were compared with those for matched controls. A health survey was conducted on a random sample of program participants at enrollment and at 12-month follow-up. The health survey included questions on asthma-related quality of life (QOL), medical utilization, productivity, and self-management skills. The percentage of patients who started controller therapy during the study period was significantly higher for the intervention group than the control group (20.7% versus 18.1%, p < 0.001). The controller prescription fill rate increased significantly in the intervention group compared with controls (p < 0.0001); the increase was primarily driven by increased refill rates for patients already using controllers. Reliever prescription fill rates decreased for both the intervention group and controls. Program participants reported significant improvements in asthma-related QOL (p < 0.05) and self-management skills. Self-reported medical utilization decreased for office visits (p < 0.05) and emergency room visits (p < 0.01). A population-based asthma disease management program can improve controller prescribing rates (new therapy starts), controller adherence rates (refill persistency), and self-management skills. These changes in physician and patient behavior help close the gaps between guidelines and practice in asthma therapy.