Articles on Pharmacy Benefit Management

Polypharmacy Control Is Key for Psych Rx Savings Under Part D

Reprinted from the March 17, 2006, issue of DRUG BENEFIT NEWS, biweekly news, data and business strategies for health plans, PBMs and pharmaceutical companies.

Part D sponsors can best contain the costs of psychotropic drugs for Medicare-Medicaid dual-eligible populations via careful medication management, starting with targeting doctors responsible for the often rampant polypharmacy in elderly and disabled mentally ill patients, according to several researchers and pharmacy managers.

Such measures can help plans struggling with the onslaught of mentally ill dual eligibles in the face of CMS formulary restrictions regarding antidepressants and antipsychotics, suggests Julie Donohue, Ph.D., who is assistant professor at the Graduate School of Public Health at the University of Pittsburgh.

The two drug classes are part of six for which CMS is requiring that "all or substantially all" drugs be included in Medicare Part D formularies. In addition, in recent draft guidelines for 2007 formularies, the agency stated that plans cannot implement prior authorization or step therapy for the six classes if new enrollees are already taking a drug.

Such a policy, while protecting a vulnerable population, simultaneously limits both cost management strategies and negotiating power for Part D sponsors. Thus, plans will need to move beyond traditional utilization management and formulary restriction strategies.

"When dealing with vulnerable populations, and a set of medication classes with a high cost, a conservative approach would be provider education and profiling," Donohue tells DBN. "If.certain providers use polypharmacy and more than one antipsychotic at a time, it will likely lead to higher overall drug cost and lower quality of care in most cases," she says. "A lot of drug costs could be due to a relatively small number of prescribers who use polypharmacy."

The stakes for psychotropic costs in the face of dual-eligible populations are high. Recent statistics indicate that nearly a third of dual eligibles are mentally ill, and that on average, mentally ill Medicare beneficiaries spent 61% more on drugs than did those not suffering from psychiatric illness, according to an article in the March/April 2006 issue of Health Affairs.

For one multi-state prescription drug plan (PDP) and Medicare Advantage prescription drug plan (MA-PD) sponsor that shared data with DBN but asked to remain anonymous, for the first two months of Part D (January and February), five of the top 10 drugs in terms of spend for about 250,000 dual eligibles — antipsy-chotics Seroquel, Zyprexa, Risperdal, and Abilify, and anti-dementia agent Aricept — were behavioral health drugs, which, in total, constituted 51% of cost and 36.4% of utilization.

Although savings from sometimes-costly medication management programs for mentally ill dual eligibles and seniors may be more obvious for managed care payers that can save on long-term health care costs, stand-alone PDP plans can reap savings, too, says Mesfin Tegenu, senior vice president of pharmacy for PerformRx, the Medicaid-focused captive PBM of AmeriHealth Mercy/Keystone Mercy health plan.

He cites a PerformRx Medicaid client that experienced a 6% reduction in pharmacy cost and 9% reduction in utilization for psychotropic drugs six months after implementing an aggressive medication monitoring and physician intervention program for mentally ill patients. "Working through details and coming up with a better drug regimen has been very successful for people in this program," he notes.

Such a strategy is just as appropriate for Part D plans struggling with psychotropic drug costs for high-risk populations, he says. PDPs "need to understand that these patients have multiple prescriptions, often like 15 per month," many of which turn out not to be necessary, he tells DBN. Across PerformRx's book of business, for accounts that have dual eligibles or mentally disabled Medicaid populations, seven out of the top 10 drugs in terms of spend are behavioral health drugs, he says, accounting for 25% to 30% of drug costs on the pharmacy side.

Effective Program Has Claims Alerts, Outreach

Tegenu recommends the following elements for a successful program: medication tracking software to ensure appropriate dosing and therapy duration, including claims alerts for potential interventions; a qualifier program at the point of sale and/or member-provider education program; and, when necessary, targeted physician interventions.

Follow-up with high-risk members is also necessary, he says, especially those at risk for improper medication continuity when transferring from a hospital to outpatient status. In such cases, "unless you do an intervention, people often stay on that high dose [given in hospitals]" and keep refilling the same prescription, hurting both plans and patients.

Data unveiled this month by investment firm CIBC World Markets indicate that, in the past 12 months, of the top 20 drugs by managed care spending, psychotropic drugs accounted for nearly 20%, or $13 billion. The drugs that made the list were Zyprexa ($2.6 billlion), Seroquel ($2.5 billion), Risperdal ($2.2 billion), and antidepressants Effexor ($2.6 billion) and Zoloft, which topped the list at $3.1 billion. For payers, a reprieve for Zoloft is in sight, however — generics are expected in June.

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