Disease Mangement

DM Programs Can Fill 'Gap' Left by Suboptimal Rx Treatment

Reprinted from the April 21, 2006, issue of DRUG BENEFIT NEWS, biweekly news, data and business strategies for health plans, PBMs and pharmaceutical companies.

Disease management (DM) programs incorporating pharmaceuticals can lower overall health care costs for payers by helping fill in the "treatment gap" that often results in suboptimal or interrupted drug therapy, according to industry insiders and health plans that have implemented such initiatives. And a related strategy of lowering drug copayments in exchange for patient participation in DM programs has proven to be well worth the investment for some payers.

"You pick any disease, and there is a tremendous treatment gap — partly due to educational deficiencies — on the patient end and the provider end," Medical Outcomes Management, Inc. President Alan Kaul, Pharm.D., tells DBN. "The other gap is a patient had been on therapy and fell off because of side effects," the consultant says. The DM remedy might be both to inform doctors about the standard of care for the given disease and to follow up with patients and make sure they remain adherent to therapy, he told attendees at last month's Choices conference in La Jolla, CA, sponsored by California-based PBM MedImpact Healthcare Systems, Inc.

Payers need to approach drugs as a larger component of "the cost of treating disease," Kaul says, with a view toward reducing overall health care costs. The payoffs can be substantial: Both Kaul and other DM experts cite returns on investment (ROIs) of between $1.50 and $6 in health care savings (combined medical and pharmaceutical costs on a per-member-per-month basis) for every dollar spent on DM programs.

In an attempt to simultaneously incentivize both chronic drug compliance and DM program participation, some payers in Asheville, N.C., have paid up to 100% of pharmacy costs for medications and supplies related to diabetes since 1996 to encourage their enrollees to enter a diabetes DM program.

The initiative was first launched for employees of the City of Asheville; in 1997, the local hospital health system Mission Hospitals joined the program on behalf of its employees and signed on to coordinate it. The program has since been expanded to other chronic diseases, and now enrolls about 10% of the two payers' 12,000 collective covered lives (3,000 for Asheville and 9,000 for Mission Hospitals) in DM programs for diabetes, asthma, hypertension and cholesterol, says Barry Bunting, Pharm.D., clinical manager of the pharmacy department for the hospital system's Diabetes & Health Education Center.

Reducing Copays Can Save Money

"Yes, it is counter-intuitive to reduce medication copayments when the cost of medication already adds significantly to the growing cost of health care," Bunting acknowledges to his colleagues in a recent posting on a DM listserv. "However, we found that our health plan was spending a great deal of money on medications without gaining the benefits, because many people were not on effective medication regimens, or were taking their medications sporadically," he states. Once in DM programs, patients' medication compliance increased and emergency room visits and hospitalizations decreased, he reports, leading to overall savings.

For the diabetes group, which now has 450 enrollees, "the drug spend on diabetes medications increased significantly, but medical claims decreased even more," he says, resulting in a net savings — including program costs — of about $2,000 in total pharmacy and medical expenses per patient per year for eight consecutive years since the program's inception.

PBMs can be a useful partner in the DM process, says David Kwasny, vice president of sales and marketing for RESTAT, a Wisconsin-based PBM. Although DM programs must originate with the health plan and cannot be "PBM-driven," he maintains, PBMs can "work in conjunction with a carrier" and partner with third-party administrators to help implement the programs.

The PBM can analyze claims, identify vulnerable populations, educate them about drugs, communicate with dispensing pharmacists, ensure interventions at the point of sale and work with clients to come up with comprehensive drug management strategies tailored to the targeted population, Kwasny explains. He says it is "important to understand the payer's culture" to design a program well-matched to its population.

Medical Outcomes Management's Kaul concurs regarding the role of PBMs, but proposes additional incentives to encourage drug benefit firms to be willing collaborators in DM programs. "You can pay [PBMs] for cognitive services, drug monitoring, etc., and think about what incentives are built in for PBMs besides the usual compensation package and percentages," he says.

Thus, "maybe you could incentivize them to contribute to lowering the per-member, per-month cost of overall medical care, as opposed to just [PMPM] drug costs," he suggests.

Advertise With AIS

Privacy

Site Map