Performance Enhancing Pharmaceuticals

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Performance Enhancing Pharmaceuticals

• Alan H. Heaton, BS (Pharm), Pharm. D., RPh.
• Director of Pharmacy
• BlueCrossBlueShield of Minnesota

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Local Performance?Key Minnesota Health Care Cost
and Economic Indicators
Notes health care cost is MN privately insured
spending on health care services per person MN
economy is gross state product overall inflation
is consumer price index for the Twin Cities area
workers wages is average weekly wages for
Minnesota workers.
Source MDH, Health Economics Program
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Under Performing in Key Diseases

• Diabetes epidemic
• 17 million Americans
• 300,000 new cases of Type 2 in children each year
• Significant under-utilization of diabetes
  medications
• Coronary Heart Disease
• Recent guidelines suggest tripling number of
  people using of lipid agents
• 29 of adults with high blood pressure (60
  million) versus 25 in 1988
• Only 31 at high risk (older than 60 years,
  female, blacks) able to maintain blood pressure
  control
• Of those with hypertension and diabetes only 25
  adequately treated
• Americans Blood Pressure Climbing Again. USA
  Today. July, 2003.
• Kotchen et al. University of Wisconsin. 44,000
  responses from government National Health and
  Nutrition Examination Study. Over 15-year period.

JMCP. March 20039Supp3.
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Nationally, Hyper Performance on Drugs
Source Health Care Financing Administration
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Drivers of Drug Performance
Prescription costs are increasing annually at
14-21
Trend Drivers
Implications

• Therapeutic shift from inpatient to outpatient
  care with drug therapy
• Direct-to-consumer (DTC) advertising and
  consumer demand
• Existing drugs expanded applications and more
  aggressive treatment guidelines
• New drug improvements and new markets
• Price inflation

• More users
• More prescriptions per user
• More expensive mix
• Higher unit costs

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Utilization Mix 70 of Performance
Components of Prescription Drug Trend
Leveraging

• Mix type of prescription drugs used by
  population
• Utilization number of prescription drugs used
  by population
• Price Inflation average year-over-year increase
  in the cost of each prescription
• Leveraging erosion of effectiveness of fixed
  cost-sharing over time

Mix
Price Inflation
Utilization
Traditional employer cost management strategies
have not effectively addressed utilization and mix
1 Towers Perrin Employers, Prescription Drugs
PBMs, 2003
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Pharmaceutical Manufacturers
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Comparison of Top 50 Drugs Contributing Most to
One-Year Spending to All Other Drugs and Total
Market (2000-01)
Adapted from Prescription Drug Expenditures In
2001 Another Year of Escalating Costs. A Report
by The National Institute for Health Care
Management Research and Education Foundation Rev.
May 6, 2002.
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Performance Top 10 Drugs 2003

• US sales in billions of dollars
• Lipitor 6.8
• Zocor 4.4
• Prevacid 4.0
• Procrit 3.3
• Zyprexia 3.2
• Epogen 3.1
• Nexium 3.1
• Zoloft 2.9
• Celebrex 2.6
• Neurontin 2.4

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Current Performance
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The New Yorker, October 27, 2003
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• We make a healthy difference in peoples lives
  by utilizing pharmacy benefits that feature
  access, affordability, and appropriateness.

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Appropriate Therapy?
An estimated 44,000-98,000 people die each year
in hospitals because of medical errors -
Institute of Medicine report57,000 people die
each year because of omission they dont
benefit from known therapies - NCQA
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Appropriate Therapy!

• National MN
• Pharmacy per capita
• 543 569
• Total Healthcare per capita
• 4230 3575
• Death Rate per 100,000
• 881.9 792.2
• KFF 1999

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Promoting Appropriate Treatment

• Care SupportSM disease management program
• PrimeImpactSM provider education programs
• Prime Pharmacist Provider discussions
• 20 minute presentations/round tables at key
  clinics
• National / Local treatment guidelines
• Cost-effective prescribing
• Generic drugs
• Formulary drugs
• Care pilot program
• Blue Cross provider incentives
• Key clinical measurements
• Generic utilization

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Measuring the Impact of Collaborative
Pharmaceutical CareMay 27, 2004

• Study Architects
• Alan Heaton, BCBSM
• Brian Isetts, College of Pharmacy
• Dave Miller, Fairview/University Clinics
• Wallace Wadd, Prime Therapeutics, Inc.

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Collaborative Pharmaceutical Care (CPC) Project
History

• FPS Wins BHCAG Silver Prize (5/2000)
• AHC/FV grant awarded (7/2000)
• BCBSM partnership initiative (3/01)
• Care delivered to patients (8/01 7/02)
• Claims programming query (1/03 6/03)
• Archives of Internal Medicine Article (8/03)
• BCBSA Best Practices presentation (10/03)
• Minnesota Physician article (11/03)
• J of Gen Int Med manuscript (submitted 4/04)
• Pinnacle Award Announcement (5/04)

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Results Clinical, Drug Therapy Problems

• 629 drug therapy problems (2.2 /patient)
• 6.4 medical conditions/patient
• 7.9 drug therapies/patient
• 207 problems (33) w/ OTC medications
• 64 DTPs (10) - drugs from friends and family
• 85 of patients had at least one problem

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ECHO

• Economic outcomes
• Total health care costs 481 to 411 pppm
• Pharmacy costs 161 to 170 pppm
• Clinical outcomes
• HEDIS measures improved (HTXN, Lipids)
• Peer review, 90 of therapeutic goals attained
• Humanistic outcomes
• Patient satisfaction (CAHPS)
• Quality of life (SF-12)

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Appropriate Therapy

• Minnesota initiatives
• Avandia or Actos being used in Type II diabetic
  patients with liver dysfunction or heart failure
• Metformin prescribing in Type II diabetic
  patients with medical contraindications
• Targeted mailings are being used to identify
  physicians prescribing this combination
• Asthma intervention to help physicians identify
  patients at risk for repeat ER visits

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Aligned Strategies ROI
Source The SOLVD Investigators, NEJM
325(5)293-302, 1991
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Integration and SimplificationOne call does it
all

• One ID card for both medical and pharmacy
• One telephone number for customer service support
  for health and pharmacy benefits for members
• One Account Manager for medical and pharmacy
• One integrated Flexible Spending Account, that
  includes automatic cross-over of pharmacy claims
• One feed for Care SupportSM
• One eligibility feed
• One customized web site
• One SPD
• One contract
• One set of reports
• One billing invoice

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Predicting Performance?

• Aging Population
• Americans over 65 is expected to nearly double by
  2025
• Aggressive treatment guidelines
• Earlier use of drugs for cholesterol reduction
• New drugs in FDA approval process
• Over 4,700 currently in development (371Biotech,
  Specialty)
• Marketing dollars spent on existing drugs
• DTC
• Pricing practices of drug manufacturers
• Disengaged patients and providers

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Designing Performance

• Formulary Maintenance
• Lowest net cost
• Benefit Designs
• Closed, co-pay or coins (feature mandatory
  generics)
• 3 Tier
• Gen, Form brand, Non form brand
• Form gen, Form brand, non form
• Gen, single source brand, multi source brand
• Hybrids
• CD, high deductibles

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Formulary PerformanceValue-Based Purchasing

• Value-based purchasing represents an attempt to
  create incentives that reward quality and
  cost-effective care
• Examples
• Oregon rx drug initiative evaluate which drugs
  are the most effective within each class
• MN DHS MA DFC-PDL

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Employer Performance

• National data suggest the following
• For the most part, employers are not dropping
  coverage
• Employers are paying about the same share of
  premiums as before
• Benefit sets are changing higher deductibles,
  tiered Rx copays, etc.? shifts some additional
  cost onto employees
• A few employers are looking to new models of
  health insurance
• Minnesota-specific employer survey results,
  though still preliminary, are consistent with
  this trend

Source Kaiser Family Foundation/Health Research
and Education Trust, 2003 Employer Health
Benefits Survey MDH, 2002 Minnesota Employer
Health Insurance Survey
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Over the past 12 - 18 months, Pharmacy Management
strategies have been focused on slowing the
rapidly escalating drug trend. The rate of
increase in utilization and prescription cost has
declined over the last year.
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Biotech, Specialty Products