Articles on Pharmacy Benefit Management

Featured Health Business Daily Story January 22, 2008

'Value-Based' Prescription Drug Programs Gain Traction With Several Large Health Plans

Reprinted from HEALTH PLAN WEEK, the industry's leading source of business, financial and regulatory news of health plans, PPOs and POS plans.

Following the success of some self-funded employer groups, several large health plans are starting to roll out or expand their "value-based" prescription drug programs, which slash copayments for certain chronic medications as an incentive to improve therapy adherence and hopefully avert more expensive medical treatments.

Interest in value-based insurance designs is growing, advocates say, as data demonstrate improved health outcomes and fewer hospital and emergency-room visits. But some health plan executives also contend that more cost-benefit data are necessary before value-based drug plans will be widely adopted.

Blue Cross and Blue Shield of Michigan's HMO subsidiary Blue Care Network, for one, is considering expanding its program, which lowers the $40 copay for branded asthma-control medications to $10 generic copay levels. Launched in March 2006, the program aims to reduce dependence on rescue medications and eliminate some hospitalizations.

The asthma-drug program has resulted in a 20% to 25% increase in utilization of controller medications, says Kim Tonkavich, director of pharmacy health centers at Blue Care Network. "We saw positive outcomes in asthma," he explains. "We saw decreases in hospitalization and ER visits, but we need more than just one year's data to validate that."

Blue Care Network soon will decide whether to offer similar copay reductions sometime in 2008 for diabetes and cardiovascular drugs, Tonkavich says. The health plan is studying improved compliance rates reported by other payers. But some data suggest only "marginal increases," he says. "If you're in a therapeutic category that has a very high percentage of members on a particular therapy, and only an extremely small subset of that global population changes their [compliance] habits, you've lost the revenue from that copay for everyone for just that small subset."

The Cleveland Clinic employee health plan has seen adherence rates improve under its program that reduces copays on cholesterol-busting statin drugs. Launched in 2006, the program includes a $6 copay for a 90-day supply of generic statins and an $8 copay for the same supply of branded Lipitor or Crestor. Normal copays for branded statins are almost $100 for a 90-day supply. To get the lower copays, members must purchase their drugs from one of Cleveland Clinic's nine retail pharmacies and participate in a pill-splitting program.

Roughly 40% of the employee population's total 5,500 statin users are in the program, according to Estay Green, Pharm.D., director of pharmacy benefits at the Cleveland Clinic and PPO network Cleveland Health Network. The clinic found that 20% more members picked up all of their prescriptions for the year, he says.

Green acknowledges that copay reductions can be "hard to justify" on a cost basis in the short run, but he explains that the Cleveland Clinic's goal is to make employees and patients healthier. Expected cost savings may not be seen for 10 or 15 years, Green adds. That's why large health plans haven't been pushing this as an initiative that will save their clients money, he explains.

Still, one large health plan is moving into this space. Aetna, Inc. on Dec. 5 unveiled "Aetna Healthy Actions Rx-Savings," a program for self-funded plans that lets employers pay part or all of certain employees' copays. The program, which takes effect Jan. 1, is designed to encourage compliance with therapies shown to effectively manage conditions of high-risk members, Aetna said. Eligible employees include those who take drugs for asthma, diabetes, high cholesterol, high blood pressure and heart disease.

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