Trends and Factors Associated With Insurer Approval of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor Prescriptions

OBJECTIVES

Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is)-innovative yet costly cholesterol-lowering agents-have been subject to substantial prior authorization (PA) requirements and low approval rates. We aimed to investigate trends in insurer approval and reasons for rejection for PCSK9i prescriptions as well as associations between patients' demographic, clinical, pharmacy, payer, and PCSK9i-specific plan/coverage factors and approval.

METHODS

We examined trends in PCSK9i approval rates and reasons for rejection using medical and prescription claims from 2015 to 2017 for individuals who received a PCSK9i prescription. We used multinomial logistic regression to estimate quarterly risk-adjusted approval rates for initial PCSK9i prescriptions and approval for any PCSK9i prescription within 30, 90, and 180 days of the initial PCSK9i prescription. For a 2016 subsample for whom we had PCSK9i-specific plan policy data, we examined factors associated with approval including PCSK9i-specific plan formulary coverage, step therapy requirements, and number of PA criteria.

RESULTS

The main sample included 12 309 patients (mean age 64.8 years [SD = 10.8], 52.1% female, 51.5% receiving Medicare) and was similar in characteristics to the 2016 subsample (n = 6091). Approval rates varied across quarters but remained low (initial prescription, 13%-23%; within 90 days, 28%-44%). Over time, rejections owing to a lack of formulary coverage decreased and rejections owing to PA requirements increased. Lack of formulary coverage and having ≥11 PA criteria in the plan policy were associated with lower odds of PCSK9i prescription approval.

CONCLUSIONS

These findings confirm ongoing PCSK9i access issues and offer a baseline for comparison in future studies examining the impact of recent efforts to improve PCSK9i access.

Incentives and disincentives to drug innovation: evidence from recent literature

Aim: Drug innovation is strongly driven by economic incentives. How these incentives work in determining or changing the level of activity of innovators and the direction of their innovation remains understudied. We seek to address these issues in reviewing recent literature on drug innovation, which offers one major unifying theme of pharmacoeconomic scholarship presented at the 2019 AEA-ASSA annual convention. Methods: Drawn from three AEA-ASSA convention panel sessions, papers were reviewed for newly charted research terrains and new research trajectories, and their theoretical and practical implications on efficiency, effectiveness, and value in the production and utilization of pharmaceutical products. Results: While high and continuously rising drug prices are typically claimed as the price of scientific innovation, the reviewed literature finds that this link only partially accounts for the problem. High risk aversion owing to information asymmetries and vastly intractable uncertainties is prevalent among innovating firms. Predatory business models abound. Reverse predatory strategies also exist to maintain product exclusivity without much added clinical benefits, and to constrain generic competition. CEO compensation practices contribute to rising drug prices. Finally, the US government's hands-off policy on drug list prices leave the forces of supply and demand to allocate them and reward innovation (at times perversely), even as the government extensively regulates or over-regulates practically every other aspect of innovation. Conclusions: Price-elasticity of demand is critical in drug innovation. The drug value chain is price-sensitive to the balance of incentives and disincentives to innovation. American health policy should consider charting a middle course that introduces some form of regulatory price control, while stimulating and sustaining the benefits of market competition. That should incentivize stakeholders to take into account both resources and value for money in making decisions based on best-quality, clinical-economic evidence.

Changes in Consumer Cost-Sharing for Health Plans Sold in the ACA's Insurance Marketplaces, 2015 to 2016

This brief examines changes in consumer health plan cost-sharing--deductibles, copayments, coinsurance, and out-of-pocket limits--for coverage offered in the Affordable Care Act's marketplaces between 2015 and 2016. Three of seven measures studied rose moderately in 2016, an increase attributable in part to a shift in the mix of plans offered in the marketplaces, from plans with higher actuarial value (platinum and gold plans) to those that have less generous coverage (bronze and silver plans). Nearly 60 percent of enrollees in marketplace plans receive cost-sharing reductions as part of income-based assistance. For enrollees without cost-sharing reductions, average copayments, deductibles, and out-of-pocket limits remain considerably higher under bronze and silver plans than under employer-based plans; cost-sharing is similar in gold plans and employer plans. Marketplace plans are more likely than employer-based plans to impose a deductible for prescription drugs but no less likely to do so for primary care visits.

Patterns of use and expenses associated with mail-service pharmacy in adults with diabetes

OBJECTIVES

To identify socioeconomic factors associated with mail-service pharmacy use and compare the differences in disease-specific prescription medication and medical utilization expenses in a nationally representative sample of adults with diabetes.

DESIGN

A retrospective, longitudinal, cross-sectional study.

SETTING

United States in 2006-11.

PARTICIPANTS

Medical Expenditure Panel Survey household component (MEPS-HC) participants aged 18 years or older diagnosed with diabetes and prescribed antidiabetic medications.

MAIN OUTCOME MEASURES

Likelihood of mail-service pharmacy use, diabetes-related medical utilization, and medication expenses.

RESULTS

Among 4,430 eligible participants identified in the 2006-11 surveys, representing more than 83 million U.S. individuals, nearly 13% of the participants obtained two-thirds or more of their antidiabetic medications via mail service predominantly. Mail-service pharmacy users were older, had high school or college degrees, had higher incomes, and were more likely to be covered by private insurance. There were no significant differences in diabetes-related medical utilization and drug expenses between the two groups.

CONCLUSION

Besides pharmacy benefit design, sociodemographic and economic factors influenced drug dispensing channel use (mail service versus community pharmacy). No significant differences in diabetes-related drug and medical expenses between mail-service and community pharmacy users were observed.

[The relevance of multiple sclerosis drugs in private health insurance (PHI)]

The development of expenses and prescriptions in the pharmacotherapy for multiple sclerosis (MS) is examined on the basis of prescription data of 14 PHI firms. The drugs for the treatment of MS are among the most top-selling drugs in the PHI. From 2007 to 2012, the expenses increase 2.33-fold. The main cause is the increas of the prescription figures. In 2012, about 8,400 privately insured persons receive an MS drug. The prevalence of MS is 2.3 times higher in women than in men Impro ved diagnostic possibilities and expensive new drugs will lead to a dynamic cost de velopment in the next years.

Design, implementation, and first-year outcomes of a value-based drug formulary

BACKGROUND

Value-based insurance design attempts to align drug copayment tier with value rather than cost. Previous implementations of value-based insurance design have lowered copayments for drugs indicated for select "high value" conditions and have found modest improvements in medication adherence. However, these implementations have generally not resulted in cost savings to the health plan, suggesting a need for increased copayments for "low value" drugs. Further, previous implementations have assigned equal copayment reductions to all drugs within a therapeutic area without assessing the value of individual drugs. Aligning the individual drug's copayment to its specific value may yield greater clinical and economic benefits. In 2010, Premera Blue Cross, a large not-for-profit health plan in the Pacific Northwest, implemented a value-based drug formulary (VBF) that explicitly uses cost-effectiveness analyses after safety and efficacy reviews to estimate the value of each individual drug. Concurrently, Premera increased copayments for existing tiers.

OBJECTIVE

To describe and evaluate the design, implementation, and first-year outcomes of the VBF.

METHODS

We compared observed pharmacy cost per member per month in the year following the VBF implementation with 2 comparator groups: (1) observed pharmacy costs in the year prior to implementation, and (2) expected costs if no changes were made to the pharmacy benefits. Expected costs were generated by applying autoregressive integrated moving averages to pharmacy costs over the previous 36 months. We used an interrupted time series analysis to assess drug use and adherence among individuals with diabetes, hypertension, or dyslipidemia compared with a group of members in plans that did not implement a VBF. 

RESULTS

Pharmacy costs decreased by 3% compared with the 12 months prior and 11% compared with expected costs. There was no significant decline in medication use or adherence to treatments for patients with diabetes, hypertension, or dyslipidemia.

CONCLUSIONS

The VBF and copayment changes enabled pharmacy plan cost savings without negatively affecting utilization in key disease states.

The effects of prior authorization policies on medicaid-enrolled children's use of antipsychotic medications: evidence from two mid-Atlantic states

OBJECTIVE

The purpose of this study was to examine the impact of prior authorization policies on the receipt of antipsychotic medication for Medicaid-enrolled children.

METHODS

Using de-identified administrative Medicaid data from two large, neighboring, mid-Atlantic states from November 2007 through June 2011, we identified subjects <18 years of age using antipsychotics, from the broader group of children and adolescents receiving behavioral health services or any psychotropic medication. Prior authorization for antipsychotics was required for children in State A <6 years of age from September 2008, and for children <13 years of age from August 2009. No such prior authorizations existed in State B during that period. Filled prescriptions were identified in the data using national drug codes. Using a triple-difference strategy (using differences among the states, time periods, and differences in antidepressant prescribing rates among states over the same time periods), we examined the effect of the prior authorization policy on the rate at which antipsychotic prescriptions were filled for Medicaid-enrolled children and adolescents.

RESULTS

The impact of prior authorization policies on antipsychotic medication use varied by age: Among 6-12 year old children, the impact of the prior authorization policy on antipsychotic medication prescribing was a modest but statistically significant decrease of 0.47% after adjusting for other factors; there was no effect of the prior authorization among children 0-5 years.

CONCLUSIONS

Prior authorization policies had a modest but statistically significant effect on antipsychotic use in 6-12 year old children, but had no impact in younger children. Future research is needed to understand the utilization and clinical effects of prior authorization and other policies and interventions designed to influence antipsychotic use in children.

Do changes in drug coverage policy point to an increased role for cost-effectiveness analysis in the USA?

Compared with other countries, cost-effectiveness analysis has traditionally had a limited role in US health care. Rather, US payers have typically accommodated the introduction of expensive technology by passing an increasing proportion of costs to patients, through raising insurance premiums and/or by increasing copayments, coinsurance, and deductibles. However, in what may prove to be a tipping point, the two largest pharmacy benefit managers have chosen to exclude drugs from their formularies that offer uncertain health benefit compared with cheaper alternatives. This paper argues that cost-effectiveness analysis should be used to inform these value-based decisions, and that by using information other than robust cost-effectiveness evidence, payers risk wrongly denying beneficiaries access to important medical technologies. If cost-effectiveness analysis were to be used in this way, it would be another in a growing number of examples of its use across public and private payers. In the absence of a centralized agency conducting cost-effectiveness analysis, the recently inaugurated 2nd Panel on Cost-Effectiveness in Health and Medicine has an important role to play in standardizing methods and promoting best practice.

Demographic and economic characteristics associated with sole county pharmacy closures, 2006-2010

Key Findings. Twenty-five counties lost their sole community pharmacy between May 2006 and December 2010. Among these: (1) The average population density is 10.4 persons per square mile, compared to 87.4 for the United States. (2) The average population decreased by 1.6% between 2000 and 2010. Excluding the largest county, the average decrease was 2.4%. (3) The population age 65 years and older increased 5.4% between 2000 and 2010. Excluding the largest county, the 65-and-older population increased 2.1%. (4) The average change in the percentage of persons in poverty increased by 0.6 points between 2000 and 2010, from 15.5% to 16.1%, compared to a 4.0 point increase (11.3% to 15.3%) for the United States. (5) The average percentage of people younger than 65 years without health insurance was 24.6% in 2010, compared to 16.2% for the United States. (6) Nineteen of the 25 counties were designated "whole county" Health Professional Shortage Areas (HPSAs), meaning there was a shortage of primary medical care physicians across the entire county. (7) The average number of active doctors per 1,000 persons was 0.44, compared to 2.86 for the United States. Six of the 25 counties (24%) had no active MDs or DOs in 2010.

From the city to the bush: increases in patient co-payments for medicines have impacted on medicine use across Australia

AIM

To determine whether the national declines in prescription medicine use occurring after the 2005 21% increase in co-payments affected all areas of Australia or were specific to remote and disadvantaged areas.

METHODS

Observed dispensing of proton pump inhibitors (PPIs) and statins were obtained for 1392 statistical local areas (SLA) of Australia in 2004 and 2006. Expected dispensing was based on national dispensing rates and was age standardised to each SLA. Expected dispensing for 2006 was based on pre-2005 prescription trends. Ratios of observed to expected dispensing (dispensing ratios) for each SLA were calculated. Mean dispensing ratios for each medicine and year were calculated for all remoteness and disadvantage groups. Generalised regression models compared the percentage change in dispensing ratios from 2004 to 2006.

RESULTS

Between 2004 and 2006 PPI dispensing fell significantly in major cities (-13.7%, 95% CI=-17.3--9.8), inner regional (-14.0, 95%CI=-19.5--8.2), outer regional (-14.6%, 95%CI=-19.9--9.0) and remote areas (-9.4%, 95%CI=-16.4--1.8). Statin dispensing fell in all groups but the most remote (range 6-7%). When focussing on disadvantage, PPI dispensing fell significantly in all groups (range 12-15%). Statins dispensing did not fall significantly in the most disadvantaged areas (-2.9%, 95%CI=-8.6-3.2) but did in the least (-6.5%, -11.3--1.5) and second-least (-5.8, -10.5--0.9) disadvantaged areas. Dispensing of PPIs and statins in the most remote and disadvantaged areas remained substantially below levels expected for Australia after the 21% co-payments increase.

CONCLUSIONS

The findings suggest that the 2005 21% in patient co-payments adversely affected prescription medicine use in all areas of Australia and was not specific to remote or disadvantaged areas. Indeed, dispensing of statins fell significantly in all but the most remote and disadvantaged areas, and the existing gap in dispensing of PPIs and statins was not widened by the co-payments increase. PPIs, which are used at above-prevalence rates in Australia and have cheaper over-the-counter substitutes available, were more sensitive to co-payment increases than were statins.

A new entity for the negotiation of public procurement prices for patented medicines in Mexico

PROBLEM

As countries expand health insurance coverage, their expenditures on medicines increase. To address this problem, WHO has recommended that every country draw up a list of essential medicines. Although most medicines on the list are generics, in many countries patented medicines represent a substantial portion of pharmaceutical expenditure.

APPROACH

To help control expenditure on patented medicines, in 2008 the Mexican Government created the Coordinating Commission for Negotiating the Price of Medicines and other Health Inputs (CCPNM), whose role, as the name suggests, is to enter into price negotiations with drug manufacturers for patented drugs on Mexico's list of essential medicines.

LOCAL SETTING

Mexico's public expenditure on pharmaceuticals has increased substantially in the past decade owing to government efforts to achieve universal health-care coverage through Seguro Popular, an insurance programme introduced in 2004 that guarantees access to a comprehensive package of health services and medicines.

RELEVANT CHANGES

Since 2008, the CCPNM has improved procurement practices in Mexico's public health institutions and has achieved significant price reductions resulting in substantial savings in public pharmaceutical expenditure.

LESSONS LEARNT

The CCPNM has successfully changed the landscape of price negotiation for patented medicines in Mexico. However, it is also facing challenges, including a lack of explicit indicators to assess CCPNM performance; a shortage of permanent staff with sufficient technical expertise; poor coordination among institutions in preparing background materials for the annual negotiation process in a timely manner; insufficient communication among committees and institutions; and a lack of political support to ensure the sustainability of the CCPNM.

Canadian pharmacare: looking back, looking forward

Despite Canadians' pride in medicare and the values underpinning it, the system is conspicuously incomplete. Universal public health insurance in Canada ends as soon as a patient is handed a prescription to fill; yet prescription drugs are the second largest component of health system costs. We look back at key moments in Canadian healthcare history that shaped our pharmacare system - or lack thereof. We look forward to changes in demography and technology that will increase the need for pharmacare reform in the near future. We conclude that meaningful public engagement in pharmacare design may generate the clarity of goals and level of political support needed should windows of policy opportunity open again.

Americans' access to prescription drugs stabilizes, 2007-2010

Despite the weak economy and more people lacking health insurance, the proportion of Americans reporting problems affording prescription drugs remained level between 2007 and 2010, with more than one in eight going without a prescribed drug in 2010, according to a new national study from the Center for Studying Health System Change (HSC). While remaining stable overall, access to prescription drugs improved for working-age, uninsured people, likely reflecting a decline in visits to health care providers, as well as changes in the composition of the uninsured population. Likewise, elderly people eligible for both Medicare and Medicaid saw a sharp drop in prescription drug access problems. The most vulnerable people--the uninsured, those with low incomes, people in fair or poor health, and those with multiple chronic conditions--continued to face the most unmet prescription needs. For example, 48 percent of uninsured people in fair or poor health went without a prescription drug because of cost concerns in 2010, almost double the rate of insured people with the same reported health status.

The unintended (and costly) effects due to the introduction of an unrestricted reimbursement policy for atypical antipsychotic medications in a Canadian public prescription drug program: 1996/97 to 2005/06

BACKGROUND

Due to the increasing costs of pharmaceuticals, drug benefit programs often implement various policies that limit availability of drugs. These policies can have unforeseen consequences.

OBJECTIVES

To examine the utilization and expenditures for antipsychotic medications in a provincial government community-based drug program over a 10-year period when atypical antipsychotics were introduced and multiple reimbursement policy changes with respect to these agents were employed.

METHODS

Retrospective analysis of the Newfoundland and Labrador Prescription Drug Program (NLPDP) claims database from 1996/97 to 2005/06. Antipsychotic medication utilization and expenditure were measured and effects of changes in reimbursement policies examined. Excess expenditure was measured by subtracting the actual from modelled expenditure under different policies.

RESULTS

Between 1996/97 and 2005/06, the number of prescriptions for antipsychotic medications increased by 75% and expenditures by more than 720% to $7.2 million (peaking at $7.9 million in 2003/04), with atypical agents making up 96% of the total. Expenditure for antipsychotic medications grew by an annual average rate of 26.3%. At the same time, the number of people enrolled in the drug program declined by an annual average rate of 1.13%. The total excess amount of money spent was $266,195 per 1,000 beneficiaries during unlimited access to atypical agents.

CONCLUSION

There has been a substantial, unintentional, increase in the prescribing of atypical antipsychotics each year in Newfoundland and Labrador over the 10 years, likely due to off-label use following the unrestricted and partial restrictive access policies for these medications. Perhaps restricted access for recognized usage should be enforced.

Access to prescription drugs for Medicare beneficiaries

Despite the introduction of a Medicare outpatient prescription drug benefit in January 2006, roughly the same proportion of elderly Medicare beneficiaries in 2003 and 2007--about 8 percent--skipped filling at least one prescription drug because of cost concerns, according to a new national study by the Center for Studying Health System Change (HSC). However, over the same period, more working-age adults went without a prescribed drug because of cost, suggesting the new Medicare drug benefit may have prevented a similar deterioration in access for the elderly. But, the proportion of seniors dually eligible for Medicare and Medicaid who went without a prescribed medicine almost doubled between 2003 and 2007--from 10.8 percent to 21.3 percent. And, the new Medicare drug benefit did little to close large, longstanding prescription drug access gaps between elderly white and African-American beneficiaries, healthier and sicker beneficiaries, and lower-income and higher-income beneficiaries. For example, three times as many elderly African-American beneficiaries (17.6%) went without a prescribed medication in 2007 as white beneficiaries (6.2%). In addition, Medicare beneficiaries under age 65--typically eligible because of permanent disability or severe kidney disease--had more than three times the prescription drug access problems (27.5%) as elderly beneficiaries in 2007.

Analysis of pharmacist-provided medication therapy management (MTM) services in community pharmacies over 7 years

BACKGROUND

Although community pharmacists have historically been paid primarily for drug distribution and dispensing services, medication therapy management (MTM) services evolved in the 1990s as a means for pharmacists and other providers to assist physicians and patients in managing clinical, service, and cost outcomes of drug therapy. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA 2003) and the subsequent implementation of Medicare Part D in January 2006 for the more than 20 million Medicare beneficiaries enrolled in the Part D benefit formalized MTM services for a subset of high-cost patients. Although Medicare Part D has provided a new opportunity for defining the value of pharmacist-provided MTM services in the health care system, few publications exist which quantify changes in the provision of pharmacist-provided MTM services over time.

OBJECTIVES

To (a) describe the changes over a 7-year period in the primary types of MTM services provided by community pharmacies that have contracted with drug plan sponsors through an MTM administrative services company, and (b) quantify potential MTM-related cost savings based on pharmacists' self-assessments of the likely effects of their interventions on health care utilization.

METHODS

Medication therapy management claims from a multistate MTM administrative services company were analyzed over the 7-year period from January 1, 2000, through December 31, 2006. Data extracted from each MTM claim included patient demographics (e.g., age and gender), the drug and type that triggered the intervention (e.g., drug therapeutic class and therapy type as either acute, intermittent, or chronic), and specific information about the service provided (e.g., Reason, Action, Result, and Estimated Cost Avoidance [ECA]). ECA values are derived from average national health care utilization costs, which are applied to pharmacist self-assessment of the "reasonable and foreseeable" outcome of the intervention. ECA values are updated annually for medical care inflation.

RESULTS

From a database of nearly 100,000 MTM claims, a convenience sample of 50 plan sponsors was selected. After exclusion of claims with missing or potentially duplicate data, there were 76,148 claims for 23,798 patients from community pharmacy MTM providers in 47 states. Over the 7-year period from January 1, 2000, through December 31, 2006, the mean ([SD] median) pharmacy reimbursement was $8.44 ([$5.19] $7.00) per MTM service, and the mean ([SD] median) ECA was $93.78 ([$1,022.23] $5.00). During the 7-year period, pharmacist provided MTM interventions changed from primarily education and monitoring for new or changed prescription therapies to prescriber consultations regarding cost-efficacy management (Pearson chi-square P<0.001). Services also shifted from claims involving acute medications (e.g. penicillin antibiotics, macrolide antibiotics, and narcotic analgesics) to services involving chronic medications (e.g., lipid lowering agents, angiotensin-converting enzyme [ACE] inhibitors, and beta-blockers; P<0.001), resulting in significant changes in the therapeutic classes associated with MTM claims and an increase in the proportion of older patients served (P<0.001). These trends resulted in higher pharmacy reimbursements and greater ECA per claim over time (P<0.001).

CONCLUSION

MTM interventions over a 7-year period evolved from primarily the provision of patient education involving acute medications towards consultation-type services for chronic medications. These changes were associated with increases in reimbursement amounts and pharmacist-estimated cost savings. It is uncertain if this shift in service type is a result of clinical need, documentation requirements, or reimbursement opportunities.

More nonelderly Americans face problems affording prescription drugs

More children and working-age Americans are going without prescription drugs because of cost concerns, according to a new national study by the Center for Studying Health System Change (HSC). In 2007, one in seven Americans under age 65 reported not filling a prescription in the previous year because they couldn't afford the medication, up from one in 10 in 2003. Rising prescription drug costs and less generous drug coverage likely contributed to the growth in nonelderly Americans--from 10.3 percent in 2003 to 13.9 percent in 2007--who went without a prescribed medication. The most vulnerable people--those with low incomes, chronic conditions and the uninsured--continue to face the greatest unmet prescription drug needs. Uninsured, working-age Americans saw the biggest jump in unmet prescription drug needs between 2003 and 2007, with the proportion rising from 26 percent to almost 35 percent. At the same time, a growing proportion of working-age Americans with employer-sponsored insurance reported going without prescription medications. The number of Americans who cannot afford prescription medications is likely to grow as the economy continues to decline and the ranks of the uninsured grow.

Medicare's private plans: is more change on the way?

This article will provide a description of the Medicare Advantage program in its current form, the areas of concern that Congress and other policymakers have exposed during 2007, legislative changes that could be in store and what their impact would be on plans, and what this all could mean for the home health program.

Recent developments in health insurance, life insurance, and disability insurance case law

This survey reviews significant state and federal court decisions from 2006 and 2007 involving health, life, and disability insurance. Also reviewed is a June 2008 Supreme Court decision in the disability insurance realm, affirming that a conflict of interest exists when an ERISA plan sponsor or insurer fulfills the dual role of determining plan benefits and paying those benefits but noting that the conflict is merely one factor in considering the legality of benefit denials. In addition, this years' survey includes compelling decisions in the life and health arena, including cases addressing statutory penalties and mandated benefits, as well as some ERISA decisions of note. This year, the Texas Supreme Court held that Texas's most recent version of the prompt payment statute abolished the common law interpleader exception and allowed the prevailing adverse claimant in an interpleader action filed beyond the sixty-day statutory period to recover statutory interest and attorney fees from the insurer. Meanwhile, the Court of Appeals of New York upheld the constitutionality of a statute mandating coverage for contraceptives in those employer-sponsored health plans that offer prescription drug coverage, including those plans sponsored by faith-based social service organizations. In the ERISA context, litigants continue to fight over the standard of review with varying results. In a unique assault on the arbitrary and capricious standard of review, the Fourth Circuit found that an ERISA plan abused its discretion when it failed to apply the doctrine of contra proferentem to construe ambiguous plan terms against itself. In more hopeful news for plan insurers, the Tenth Circuit held that claimants are not entitled to review and rebut medical opinions generated during the administrative appeal of a claim denial before a final decision is reached unless such reports contain new factual information.

Impact of Medicare changes in pharmacy reimbursement on patient care: two case reports

PURPOSE

Two case reports illustrate the impact of changes in pharmacy reimbursement associated with the Medicare Prescription Drug Improvement and Modernization Act (MMA) on patient care.

SUMMARY

The Medicare Part D benefit is complex and difficult for patients to understand. A patient's personal financial situation and quality of life issues may enter into decisions about enrolling in Part D and the use of drug therapy. Local coverage decisions by the Centers for Medicare and Medicaid Services can limit access to drug therapy and raise ethical dilemmas.

CONCLUSION

Changes in pharmacy reimbursement associated with MMA has the potential to markedly impact patient care and outcomes.

Controlling prescription drug expenditures: a report of success

OBJECTIVE

To determine whether a multi-interventional program can limit increases in prescription drug expenditures while maintaining utilization of needed medications.

STUDY DESIGN

Quasi-experimental, pre-post design.

METHODS

The program included formulary changes, quantity limits, and mandatory pill splitting for select drugs implemented in phases. We assessed the short-term effects of each intervention by comparing class-specific drug spending and generic medication use before and after benefit changes. Long-term effects were determined by comparing overall spending with projected spending estimates, and by examining changes in the planwide use of generic medications over time. Effects on medication utilization were assessed by examining members' use of selected classes of chronic medications before and after the policy changes.

RESULTS

Over 3 years, the plan and members saved $6.6 million attributed to the interventions. Most of the savings were due to the reclassification of select brand-name drugs to nonpreferred status (estimated annual savings, $941,000), followed by the removal of nonsedating antihistamines from the formulary (annual savings, $565,000), and the introduction of pill splitting (annual savings, $342,000). Limiting quantities of select medications had the smallest impact (annual savings, $135,000). Members' use of generic medications steadily increased from 40% to 57%. Although 17.5% of members stopped using at least 1 class of selected medications, members' total use of chronic medications remained constant.

CONCLUSIONS

A combination of interventions can successfully manage prescription drug spending while preserving utilization of chronic medications. Additional studies are needed to determine the effect of these cost-control interventions on other health outcomes.

Trends in the prescription drug plans delivering the Medicare Part D prescription drug benefit

PURPOSE

The potential impact of the Democrat-proposed Medicare drug program reform plan; possible Congressional actions in 2007; the standard Medicare prescription drug benefit; the use of low-income subsidies (LIS); and trends in 2006 and 2007 Medicare prescription drug plan (PDP) offerings, coverage, deductibles, premiums, cost-sharing practices, and utilization management strategies are described.

SUMMARY

There is evidence that Medicare prices for prescription drugs are considerably higher than federally negotiated prices. Government negotiations with prescription drug manufacturers and a standard federal PDP are among potential Congressional actions in 2007. Seniors' annual out-of-pocket costs for prescription drugs stand to decrease by hundreds of dollars under the proposed Medicare drug program reform plan. Between 2006 and 2007, the number of PDPs offered in the U.S. increased, and the monthly premium increased for most enrollees. In 2006, approximately four million Medicare beneficiaries were projected to have prescription drug spending in the coverage gap (i.e., "doughnut hole") between partial and catastrophic coverage. Most PDPs provided no gap coverage in 2007, and an estimated 10.9 million enrollees were expected to have no gap coverage in 2007. Approximately 3.3 million low income subsidy (LIS) eligible beneficiaries did not receive assistance in 2006. Cost-sharing practices (i.e., tiered copayments for generic, preferred brand, and non-preferred brand drugs and drugs in specialty tiers) varied among PDPs and over time, sometimes as the result of changes in the PDP's negotiated price for the drug, the patent or formulary status of the drug, or the PDP's tier placement of the drug. The use of utilization management strategies, including prior authorization requirements, step-therapy requirements, limits in the quantity of medication dispensed, and specialty tiers for high-cost drugs, to control PDP costs continued or increased between 2006 and 2007.

CONCLUSION

The PDPs delivering the Medicare Part D prescription drug benefit have been and continue to be subject to change. High Medicare prices and a lack of gap coverage for enrollees remain concerns that may be addressed by Congressional action in 2007.

Antihypertensive drug medication adherence and its affecting factors in South Korea

CONTEXT

Uncontrolled hypertension attributable to low medication adherence may cause such serious complications as cardiovascular disease and stroke.

OBJECTIVES

To estimate adherence to antihypertensive drug medication of the nation's representative sample in South Korea and to identify factors affecting medication adherence.

DATA SOURCES

We obtained claims data and qualification data of compulsory from the National Health Insurance, which covers almost all Korean, and identified those who got a prescription of antihypertensives during calendar year 2004.

PATIENTS

A total of 2,455,193 patients were included as study subjects. Cumulative medication adherence (CMA) was used as an index of medication adherence. Above 80% of CMA was defined as appropriate medication adherence.

RESULTS

Average CMA in the total of 2,455,193 patients was 81.4%. Appropriate adherence (CMA >or=80%) rate was 54.7% and those whose CMA is below 50% occupied 17.9%. In multiple logistic regression analysis, probability of appropriate medication adherence decreased in female gender, as age decreased, when patients have disability, when patients' residential area were from metropolitan city to city (OR: 0.91-0.92), to rural area (OR: 0.76-0.78), to extreme rural area (OR: 0.72-0.74), prescription days per visit decreased, and the number of prescribing physicians increased.

CONCLUSIONS

Identifying these factors in a target population or community, followed by developing intervention programs to increase antihypertensive medication adherence is needed. Also, medication adherence rate produced in this study can be used as a national health index and performance indexes of various hypertension control programs.

Trends in the use of antihypertensive drugs by outpatients with diabetes in Taiwan, 1997-2003

PURPOSE

To analyze trends in AHD-use by diabetic outpatients in Taiwan over a 7-year period (1997-2003) and to see whether the trends are consistent with clinical trial outcomes and published guidelines.

METHODS

A cross-sectional survey was implemented using National Health Insurance Research Database between January 1997 and December 2003. Adult outpatients who had diagnoses of diabetes and hypertension and who had concurrent antidiabetic and antihypertensive drug claim were identified. The prescribing trends were described in terms of the prescribing rates and patterns of AHDs in each study year.

RESULTS

Of the AHDs, CCBs were the most widely prescribed class throughout the study period but the prescribing rates declined considerably over the study period. A significant downward trend was also observed for beta-blockers and other classes. Drugs acting on the RAS were the only one class showing a significant increase in prescribing rates with time. The prescribing patterns for monotherapy regimen decreased over time while those for two-, three-, and four or more drug regimens increased over time. Monotherapies maintained with CCBs, beta-blockers, diuretics, and other classes steadily declined but those maintained with drugs acting on the RAS markedly increased.

CONCLUSIONS

The use of drugs acting on the RAS showed a marked increasing trend over the course of the study. Physicians' prescribing patterns for AHD are increasingly involving multi-drug regimens. These findings may imply that management of hypertension in patients with diabetes had a positive trend toward to new clinical trial outcomes and guideline's recommendation.

In search of a corrected prescription drug elasticity estimate: a meta-regression approach

An understanding of the relationship between cost sharing and drug consumption depends on consistent and unbiased price elasticity estimates. However, there is wide heterogeneity among studies, which constrains the applicability of elasticity estimates for empirical purposes and policy simulation. This paper attempts to provide a corrected measure of the drug price elasticity by employing meta-regression analysis (MRA). The results indicate that the elasticity estimates are significantly different from zero, and the corrected elasticity is -0.209 when the results are made robust to heteroskedasticity and clustering of observations. Elasticity values are higher when the study was published in an economic journal, when the study employed a greater number of observations, and when the study used aggregate data. Elasticity estimates are lower when the institutional setting was a tax-based health insurance system.

Current Trends in Pharmacy Benefit Designs: A Threat to Disease Management in Chronic Complex Diseases

With a focus on those patients who are candidates for treatment with biologic agents, we review the impact that current pharmacy benefit trends have on patients with chronic complex diseases and how they affect opportunities for disease management in this unique patient population. Dramatic increases in health care costs have led to a variety of strategies to manage cost. Many of these strategies either limit access to care or increase the patient's responsibility for choosing and paying for care, especially for medications. These strategies have a disproportionate impact on patients with chronic complex diseases, particularly those who require the use of biologic medications. A fundamental prerequisite of disease management has been coverage of disease-modifying therapies. If current pharmacy benefit trends continue, unintended consequences will likely occur including lost opportunities for disease management. Current pharmacy benefit trends could adversely impact disease management, particularly for patients requiring the use of biologic agents. Health plans should consider innovative benefit designs that reflect an appropriate level of cost sharing across all key stake-holders, ensuring appropriate access to needed therapies. Additional research is needed to clarify the value of newer approaches to therapies or benefit design changes.

Medication therapy management survey of the prescription drug plans

OBJECTIVE

To evaluate the preliminary development and implementation plans for medication therapy management (MTM) services across plan sponsors for the Medicare Part D Prescription Drug Plans (PDPs) and provide pharmacists with insights for MTM development.

DESIGN

Cross-sectional survey.

SETTING

United States.

PARTICIPANTS

307 individual contacts from Medicare Advantage or stand-alone PDPs.

INTERVENTION

A survey comprising questions about the PDP demographics, plans and implementation, beneficiary eligibility criteria, scope of services, providers of services, and payment structure for MTM services was e-mailed and mailed in November 2005.

MAIN OUTCOME MEASURES

Descriptive and bivariate analysis of survey items.

RESULTS

A total of 97 usable surveys were completed, a 31.5% response rate. Almost all respondents had a plan in place for MTM services. The majority of PDPs perceived that MTM would have a moderate benefit to their organization. Most PDPs planned to focus efforts on diabetes, heart failure, and other forms of cardiovascular disease. Overwhelmingly, PDPs planned to follow the Centers for Medicare & Medicaid Services (CMS) mandate for criteria regarding beneficiary eligibility. Only 8.2% of respondents planned to use a "traditional" pharmacist, such as a community, long-term care, hospital, or clinic pharmacist. The majority of PDPs (53.6%) planned to employ managed care pharmacists to administer MTM services.

CONCLUSION

Pharmacists are eager to implement MTM services and are looking for PDPs to provide a path of implementation and reimbursement. Many PDPs were planning to deliver MTM services internally using health professional staff, thereby limiting the extent of participation of community, long-term care, hospital and health-system, and clinic-based pharmacists. Further research and advocacy are required to ensure that MTM services accomplish the true intent of the congressional and CMS mandates.

Community and ambulatory pharmacy: evaluation of patient care services and billing patterns before implementation of Medicare part D

OBJECTIVE

To provide a summary of community and ambulatory pharmacy practice and billing patterns for medication therapy management services before implementation of Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA).

DESIGN

Cross-sectional survey.

SETTING

Ambulatory care and community pharmacy practice settings in the United States in January 2004.

PARTICIPANTS

Members of the American College of Clinical Pharmacy Ambulatory Practice and Research Network, preceptors of the American Pharmacists Association (APhA) Community Pharmacy Residency Programs, and participants in the APhA Immunizing Pharmacist listserv.

INTERVENTIONS

E-mail invitations to participate in a Web-based survey.

MAIN OUTCOME MEASURES

Practice setting; pharmacy services performed; whether pharmacists were billing for pharmacy services; if billing, the billing technique used; if not billing, the reason for not billing.

RESULTS

Of 349 respondents, 127 (36.4%) were practicing within a physician office, while 121 (34.7%) were practicing in community pharmacies. Diabetes, anticoagulation, dyslipidemia, hypertension, and smoking cessation management services were performed significantly more often in physician offices. Immunization delivery and diabetes, dyslipidemia, and osteoporosis screenings were performed significantly more often in community settings. A total of 190 (54.5%) pharmacists stated that they were billing for pharmacy services. More community pharmacists were billing for services compared with other combined practice settings (69.2% versus 46.7%, P < .001). Top reasons identified for not billing for services were salaried position, indigent population, and discomfort with the billing process.

CONCLUSION

Valuable baseline data are provided regarding pharmacy services that have been successfully implemented in ambulatory and community practice settings and which billing techniques were used to receive reimbursement before the implementation of MMA.

Medication therapy management services in North Carolina community pharmacies: current practice patterns and projected demand

OBJECTIVE

To evaluate the types of cognitive services offered and the number of patients being served in community pharmacies, determine the number of pharmacies that plan to offer medication therapy management (MTM) services under the Medicare Part D prescription drug benefit, and assess whether current and expected practices will meet the potential needs of enrollees.

DESIGN

Cross-sectional study.

SETTING

North Carolina in January 2005.

PARTICIPANTS

1,593 community pharmacy managers.

INTERVENTIONS

Survey using a Web-based tool.

MAIN OUTCOME MEASURES

Provision of cognitive services and number of patients for whom services are provided.

RESULTS

A total of 262 (16%) pharmacy managers provided usable responses. Approximately 42% of respondents (n = 110) indicated that they provide some type of cognitive service. Comprehensive MTM services, or services consistent with the professionwide consensus definition, were provided by 31% of respondents (n = 81). Independent pharmacies were more likely to offer some type of service compared with chain pharmacies (58% versus 31%, respectively; P < .001). Pharmacy managers with a doctor of pharmacy degree were less likely than pharmacy managers with a bachelor's degree to offer services in their pharmacies (P = .02), and pharmacies with pharmacists on staff who had received certificate training were more likely to offer cognitive services (P = .03). Of all respondents, 28% (n = 73) indicated that they planned to offer MTM services under the Medicare Part D prescription drug benefit.

CONCLUSION

Comparing these results with those of a 1999 survey of North Carolina pharmacists that used some of the same items, the percentage of community pharmacies that provide cognitive services has increased in the intervening years but remains low. Among the services being offered in 2005, most were focused on patient education and training, coordinating and integrating care, and medication regimen reviews. Implementation of MTM services under the Medicare Part D prescription drug benefit should hasten the development and offering of these services in community pharmacies.

Transition to Medicare Part D: an early snapshot of barriers experienced by younger dual eligibles with disabilities

OBJECTIVE

This study assessed the impact of transition from Medicaid drug coverage to Medicare Part D on a sample of dually eligible adults younger than age 65 years with disabilities.

STUDY DESIGN

Telephone survey of employed adults participating in the Kansas Medicaid Buy-In program, Working Healthy, about their experiences in accessing medications after their transition to Part D.

METHODS

A total of 328 (55%) individuals from a random sample of 600 agreed to participate in a survey administered by a university-based research unit during February and March 2006, which included 18 questions with yes/no, multiple choice, and open-ended responses. Participants resembled other Kansas dual eligibles demographically and medically, other than having slightly higher rates of mental illness and lower rates of mental retardation and some physical conditions. Participants' 2004 Medicare and Medicaid claims data were analyzed to obtain an overview of their comorbidities and previous prescription use.

RESULTS

Twenty percent of participants reported difficulty obtaining medications, including drugs in Part D-protected classes; 13% were required to switch medications; and 8% stopped taking at least 1 medication. More than half did not know they could change plans monthly, potentially improving their access to medications.

CONCLUSION

The high incidence of access problems despite Centers for Medicare & Medicaid Services (CMS) safeguards points to the need for ongoing monitoring of Part D. If the problems persist, CMS must be willing to modify the program and/or better enforce the rules already in place to avoid adverse outcomes for beneficiaries with disabilities.

Medicare Part D: where we are and where we're going

Achieving optimum outcomes for our patients clearly is going to require more than making the correct diagnosis and writing the right prescription. If patients cannot access the prescriptions needed to achieve the desired outcome, providers will be judged falling short of the mark. Achieving optimum outcomes requires not only understanding Medicare Part D, but also using this knowledge to develop an efficient and effective office system to gain access to all medically necessary prescriptions.