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AMCP: Looking at the Evidence: Studies Shed Light on Issues Affecting Managed Care
In a session entitled “Research and Evidence Podium” at the AMCP Nexus meeting, a panel of experts discussed data from several studies that shed light on a number of issues affecting managed care.
Some of the issues discussed were the impact on outcomes when the pharmacy team manages medication prior authorization in primary care practices, the impact of plan cost sharing on medication adherence and utilization, access and utilization of drugs due to changes by the Affordable Care Act, and real-world outcomes of hormonal treatment of advanced infertility treatments and their costs.
Pharmacy Management of Medication Prior Authorization Results in Improved Efficiency and Patient Outcomes
James M. Gagnon, Jr, PharmD, manager of pharmacy operations, New England Quality Care Alliance, presented data on a pilot program that looked at the effect of medication prior authorization (PA) in primary care practices on outcomes when the pharmacy team manages PA on behalf of physicians and nurse practitioners. The rationale for the pilot program, according to Dr Gagnon, was to alleviate provider and practice administrative burden and maximize communication in practice and to the patient.
Over the fiscal year 2015, from January through September, a total of 44 practitioners were enrolled in the program. As of September 18, 2015, a total of 539 PAs were submitted, of which 256 were approved and 201 denied. A total of 385 patients were contacted with an average time of 29 minutes to complete the PA. Most (95%) of PAs were submitted in 24 hours or less.
“Utilization of a certified pharmacy technician, with oversight from a pharmacist, reduces the dedicated primary care practice time needed to manage medication prior authorization requests,” said Dr Gagnon.
Along with practice time saved, another benefit of the program was patient satisfaction as well as a return on investment of 5:1.
“By collaborating with our pharmacy team for support in this area, primary care practice staff was able to utilize the time saved to provide other health care services to their patients,” said Dr Gagnon, adding that the improved efficiency found in the program also “increased the likelihood that patients will receive the appropriate medication sooner.”
Medication Adherence Decreases as Co-pays Increase
Douglas Mager, MA, director of research, Express Scripts, presented data from a study that looked at the impact of plan sponsor cost sharing on utilization of specialty medications. “As the specialty medication landscape rapidly becomes more expensive, plan sponsors continue to look for innovative ways to implement co-pay/coinsurance designs that influence their patients to become smarter consumers,” said Mr Mager.
The goal of the study, undertaken to better understand the relationship between the average specialty medication co-pay and utilization of specialty medications, was to determine if higher levels of average co-pay for specialty medications were associated with lower levels of medication utilization.
The study included 1065 plan sponsors grouped into segments based on their average specialty co-pay amounts. Of the 1065 plan sponsors, 914 (85.8%) had a co-pay segment of $0-$100 for its members, 106 (10.0%) had a co-pay of $101-$250, 28 (2.6%) had a co-pay of $251-$500, and 17 (1.6%) had a co-pay of >$500.
The study found that medication utilization dropped when co-pays exceeded $250 per prescription, with a drop in utilization of 51% in patients paying between $251-$500 in co-pays and by 89% in patients paying $501 or more in co-pays. Patients who paid between $101-$250 had a drop of 20% in medication utilization.
“Our research shows that when co-pays exceed $250 per prescription, patients become less likely to adhere to their medication therapies,” said Mr Mager. “While controlling costs is a key consideration for plan sponsors, cost-shifting strategies should never go so far that they discourage medication adherence.”
Increasing Challenges to Accessing Branded Pharmaceuticals
Under changes in the Affordable Care Act, getting access to branded pharmaceuticals is becoming increasingly challenging. This was a main finding of a study that used data from the Centers for Medicare & Medicaid Services (CMS) to look at how various health plans are annually changing access and utilization of drugs in their formularies through various management tools including prior authorization, quantity limits, co-pays, and deductibles. The study looked at the top 100 selling drugs for Medicare Part D in the top 5 states that cover about 116 million lives.
Saurabh Aggarwal, PhD, principal and co-founder, NOVEL Health Strategies, presented the results of the study that analyzed access trends of these top 100 drugs as well as access to individual drugs.
The study found that 43.11% of coverage was as a preferred brand (27.75% at specialty tier) and 24.98% as a non-preferred brand in 2015. Compared to 2014, these results show an absolute increase of 2% in specialty tier in 2015, a decrease of 3.37% in preferred brand coverage, and an increase of 1.16% in non-preferred brand coverage.
In terms of tier status, the study found an absolute percentage of plans with coverage at Tier 3 decreased
by 2.31% in 2015 from 2014, whereas coverage in Tier 5 significantly increased by 7.57%.
When looking at utilization controls, the study found a significant increase in prior authorization of 3.99% in 2015 compared to 2014, as well as an increase of 1.15% in quantity limits, and a 5.43% decrease in plans with no restrictions.
“As the majority of the formulary coverage for expensive branded drugs further shifts to Tiers 4 and 5, it will make it challenging for managed care organizations (MCOs) to negotiate with pharma companies for pricing and rebate discounts,” said Dr Aggarwal. “Increase in prior authorizations poses higher administrative burden for MCOs, physicians’ offices, and patients, and there will be an increasing need for additional documentation for approving a drug claim.”
Use of Medical and Pharmacy Claims Shows Effectiveness of Advanced Fertility Treatments
By using pharmacy and medical claims to evaluate the real-world efficacy and cost of advanced infertility treatments, investigators found no difference in fertility outcomes between patients treated with follicle stimulating hormone (FSH) and FSH + human menopausal gonadotropins (hMG). However, pharmacy costs of FSH +hMG were significantly higher than FSH even though patients treated with FSH alone used more intrauterine devices compared to patients treated with FSH + hMG, according to Andrew M. Howe, PharmD, director, health economics & outcomes research, EMD Sorono.
Pharmacy costs for patients treated with FSH compared to FSH + hMG were $6782 vs $8076 (P<.001). Other health care resource utilization costs (ie, laboratory and diagnostic, outpatient, emergency department) were similar between the 2 treatment groups.
According to Dr Howe, the study is one of the first real-world evaluations of outcomes and cost associated with different infertility treatments.
However, he said that the outcomes found in the study may indicate differences in patient characteristics that the investigators were not able to measure and he emphasized the many limitations that still remain in understanding these clinical characteristics and interpreting these real-world data.
“Not all of the factors known to impact in vitro fertilization outcomes were available in the claims data,” he said. “Although the current analysis did not detect a difference in fertility outcomes, it is possible that fac-tors better measured in a clinical database, such as oral contraceptive/progesterone use, infertility diagnoses, number of embryos transferred, or stage of embryo development may result in different conclusions.”
Dr Howe said the study “may offer new insights for decision makers to evaluate real-world effectiveness of advanced infertility treatments and costs, through the integration of medical and pharmacy claims.” —Mary Beth Nierengarten
