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AIS's Health Business Daily
Featured Story April 16, 2008 As Prescription Drug Costs Rise, Some Health Plans and PBMs Are Putting a Higher Priority on Improving Interactions With PhysiciansReprinted from DRUG BENEFIT NEWS, biweekly news, data and business strategies for health plans, PBMs and pharmaceutical companies. By Neal Learner, Managing Editor, (nlearner@aispub.com) With prescription drug spending expected to rise steeply again after a period of modest Rx price growth, some health plans and PBMs are stressing the need to work closely with a key health care stakeholder: physicians. PBM and plan pharmacy executives contacted by DBN say developing a collaborative relationship with doctors is crucial to maximizing their members' pharmacy benefit, which can improve clinical outcomes and rein in costs. Pharmacy executives contend that their goal is to make drug management tools, such as prior authorization and step therapies, as seamless as possible with doctors. Some plans and PBMs also are taking a proactive approach with doctors, discussing therapeutic alternatives with high prescribers and adopting pay-for-performance (P4P) incentives around the Rx benefit. Doctors say they have long grown accustomed to working with PBMs and health plans to resolve drug formulary issues. But a community pharmacist, who interacts with both physicians and PBMs, contends that the number of prior authorizations (PAs) has soared in recent years, causing increased headaches for both pharmacists and doctors' offices. Meanwhile, drug spending is expected to accelerate in the coming years, reaching almost $515.7 billion in 2017, more than double the $231.3 billion projected for 2007, according to a study published Feb. 26 in the journal Health Affairs. One PBM executive acknowledges his industry's relationship with physicians has had challenges. "Historically doctors would probably love nothing more than to take a patient and give a prescription and have the patient go to the pharmacy, and that would be the end of it," says Brian Solow, M.D., medical director for clinical programs at Prescription Solutions, a PBM division of UnitedHealth Group. "Physicians in the past have seen PBMs as maybe interfering with the practice, but now they understand that [PBMs are] here and here to stay," he tells DBN. "We're trying to get the word out that the PBM is there to maximize the patients' benefit, which hopefully in turn will make the physician's life easier by helping the patient control their disease and get the proper medications. The trick is how to do that and get that word out." Solow, a practicing physician for 20 years who recently joined Prescription Solutions, says anything that makes the physician's life harder is seen as a negative, including delays in adjudicating a PA. At Prescription Solutions, he says, the process takes a matter of minutes. "Other PBMs have a mandatory fax, which you will not hear [back from] for 24 to 36 hours. But ours is adjudicated very quickly," he asserts. "My goal is to make us the most physician-friendly PBM. We're reaching out doctor to doctor." Jasmine Moghissi, M.D., who runs a family medical practice in Fairfax, Va., says dealing with PAs is time consuming. The process, she adds, differs among the dozen health plans and PBMs that cover her patients. "Sometimes you have a form to fill out, other times you have to call," Moghissi says, adding that a telephone call is not always the most efficient method. "Calling is always potentially problematic, because it depends on how long you're on hold," she says. Moghissi notes that drug representatives and, less frequently, health plans will visit to discuss certain drugs and where they fall on a formulary. "In primary care, I deal with so many drugs and so many insurance companies, that [it] doesn't do me any good to have them come in," she says. "You just sort of pick [a drug], hope it flies, and if it doesn't, somebody has to deal with it." Reaching Out to MDs, Implementing P4P BlueCross BlueShield of Tennessee (BCBSTN) says it works closely with physicians in its network to lower Rx spending. The plan has six clinical pharmacists across the state that visit between 35 and 40 doctors each month to discuss prescribing alternatives. "We're taking a play from drug companies," Terry Shea, Pharm.D., director of pharmacy management at BCBSTN, says in an interview. "These pharmacists go out and visit our high-writing prescribers, and bring to them copies of our preferred drug lists [and] information about their patients who are Blue Cross members. We can show them a member who is on a brand when generics have just been released. So the physicians know when these things are happening." Shea doesn't rule out the possibility of a P4P indicator around the pharmacy benefit in the future. There are some Healthcare Effectiveness Data and Information Set (HEDIS) measures for prescription drugs, including the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) in diabetics with kidney dysfunction, and the use of beta blockers, aspirin and cholesterol-lowering drugs after a heart attack, he says. A P4P program around such Rx measures would present unique challenges, Shea acknowledges. "Physicians will say, 'I don't know why you can stratify me on that drug. I wrote the prescription, [but the patient] just never went and got it filled,'" he says, adding there would have to be some "give and take" around this measure. The implementation of a P4P program around pharmacy, in fact, would be another good reason for doctors to move toward electronic prescribing, Shea says. "We could measure whether [the doctor] wrote that prescription and [the patient] did not get it filled," he explains. "We can intervene and talk to [the patient] and say, "You know, your doctor wrote that prescription and you didn't get it filled. Is there a reason why not?'" On the other hand, Shea says that BCBSTN wants to stay clear of controversial P4P programs that offer doctors a cash payout for prescribing certain drugs. The Wall Street Journal in January reported that some health plans are drawing scrutiny for paying doctors $100 each time they switch a patient from Pfizer Inc.'s cholesterol-lowering drug Lipitor (atorvastatin) to a generic alternative. The P4P initiative BCBSTN is proposing "looks at adding a factor to their fee schedule, so it is across the board, and not just every time they write a generic they get a $5 check or something like that," Shea says. Pharmacist Sees Spike in PAs Meanwhile, one pharmacist contends PBMs' administrative regulations are getting more onerous. "The prior-authorization process was kind of rare a few years ago, with a few drug classes," says David Shirley, Pharm.D., pharmacy manager of an independent pharmacy in Charleston, S.C. "It now is becoming a complete bottleneck in community pharmacy and the physicians' offices," he tells DBN. Shirley asserts that even some very inexpensive generics are now facing PA. "I know certain, more expensive drugs are covered, and cheap generics aren't," he said, declining to name the PBM in those restrictions. "The only explanation I can come up with is there's got to be some kind of back-door deal making going on." He argues that PBMs should become more transparent in their pricing, and offer an explanation as to why certain low-cost drugs are facing PA. Furthermore, resolving
a PA can take days, Shirley adds. But not all PBMs provoke Shirley's
wrath. "A few have done a good job," he says. "I called
a company on behalf of a patient [for a] prior authorization. The physician
needed to be contacted to switch a patient," he recalls. "The
PBM said, 'We'll call the physician and patient for you, and we'll call
you back when it's done. My chin fell to the floor. That was the first
time in hundreds of calls that that happened." |
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