Beneficiary Medication Adherence and Managing Pharmacy Costs
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1 Beneficiary Medication Adherence and Managing Pharmacy s Hae Mi Choe, PharmD Director, Innovative Ambulatory Pharmacy Practices University of Michigan Hospitals and Health Centers Clinical Associate Professor of Pharmacy University of Michigan College of Pharmacy
2 Objectives Describe the impact of medication non-adherence on overall health care cost and quality of care Identify key barriers to medication adherence Review the impact of high drug costs for patients on adherence especially during coverage gap Discuss different strategies to avoid the coverage gap and decrease out of pocket costs Discuss the importance of comprehensive medication review to improve adherence and lower drug costs Describe University of Michigan Health System approach to managing high medication costs
3 Impact of Medication Non-adherence 75% of healthcare dollars are spent on chronic conditions (1.3 trillion dollars annually) Poor medication adherence Rates have been estimated to be as low as 50% Causes 33-69% of drug-related hospital admissions Increases risk of disease progression Leads to poor outcomes Total financial impact of non-adherence is estimated at $290 billion annually
4 Key Barriers to Medication Non-adherence Medication cost High co-pay or out of pocket cost Regimen complexity Increased regimen complexity Medication beliefs Perceived risks of having a side effect Perceived impact and need for the medication Depression In patients with diabetes Gellad, W., J. Grenard, and A. McGlynn. "A Review of Barriers to Medication Adherence: A Framework for Driving Policy Options." Rand Health Technical Report
5 Current Medicare Part D Structure Initial coverage period copayment or coinsurance Coverage gap or doughnut hole starts when total drug costs > $2, % discount on brand-name formulary drugs 21% discount on all generic formulary medications Catastrophic coverage period starts when out-of-pocket costs > $4,750 $2.65 (generic)/$6.60 (brand) OR 5% of drug cost
6 Impact of Coverage Gap Doughnut Hole Medicare part D coverage gap intended to sensitize patients to drug costs Encourage patients to switch to cost effective alternative treatments Patients in the coverage gap Twice as likely to discontinue therapy Less likely to switch 1 Polinski, J. "Changes in Drug Utilizaion during a Gap in Insurance Coverage: An Examination of the Medicare Part D Coverage Gap." PLOS Medicine:. N.p., n.d. Web. 08 May <
7 Future Coverage Gap (Brand Drugs) Plan Year Beneficiary -Sharing Plan -Sharing Manufacturer -Sharing % 2.5% 50% % 2.5% 50% % 5% 50% % 5% 50% % 10% 50% % 15% 50% % 20% 50% % 25% 50%
8 Future Coverage Gap (Generic Drugs) Plan Year Beneficiary -Sharing Plan -Sharing Manufacturer -Sharing % 21% 0% % 28% 0% % 35% 0% % 42% 0% % 49% 0% % 56% 0% % 63% 0% % 75% 0%
9 Tips for Reducing Medication s Therapeutic interchange Least expensive brand Combination pill Maximize therapeutic dose Pill splitting Separate tubes of combination creams Community pharmacy discount programs
10 Therapeutic Interchange Drug Name Full Drug Initial Gap Catastrophic Diovan $118 $41 $56 $7 Drug Name Full Drug Initial Gap Catastrophic losartan $8 $5 $7 $3 *Monthly costs
11 Therapeutic Interchange Drug Name Full Drug Initial Gap Catastrophic Detrol LA $195 $41 $93 $10 Drug Name Full Drug Initial Gap Catastrophic oxybutynin $9 $7 $7 $7 *Monthly costs
12 Least Expensive Brand Drug Name Full Drug Initial Gap Catastrophic Lantus $138 $41 $66 $7 Drug Name Full Drug Initial Gap Catastrophic Novolin NPH $80 $41 $38 $7 *Monthly costs for 1 vial of insulin. Switching to NPH requires BID dosing.
13 Combination Pills Drug Name Full Drug Initial Gap Catastrophic lisinopril 20 mg $7 $5 $5 $3 HCTZ 12.5 mg $15 $5 $11 $3 Drug Name Full Drug Initial Gap Catastrophic lisinopril 20 mg/ HCTZ 12.5 mg $7 $5 $5 $3 *Monthly costs
14 Maximize Therapeutic Dose Drug Name Full Drug Initial Gap Catastrophic Drug Name Full Drug Initial Gap Catastrophic metformin 500mg/ glyburide 2.5mg $9 $5 $7 $3 Vytorin (ezetimibe 10mg simvastatin 20mg) $166 $90 $79 $8 Drug Name Full Drug Initial Gap Catastrophic Drug Name Full Drug Initial Gap Catastrophic metformin 1,000 mg $9 $5 $7 $3 simvastatin 40 mg $7 $5 $5 $3 *Monthly costs
15 Pill Splitting Drug Name Full Drug Initial Gap Catastrophic Crestor 10 mg (1 tab) $169 $41 $80 $8 Drug Name Full Drug Initial Gap Catastrophic Crestor 20 mg (1/2 tab) $85 $41 $41 $7 *Monthly costs
16 Separate Tubes of Combination Creams Drug Name Full Drug Initial Gap Catastrophic nystatin/ triamcinolone $233 $7 $184 $12 Drug Name Full Drug Initial Gap Catastrophic nystatin $28 $7 $22 $7 triamcinolone $8 $7 $6 $7 *Monthly costs
17 Patient Case Mrs. Smith comes into the pharmacy to pick up her medications. She is told that her co-pay doubled. Mrs. Smith can t afford to pay for her medications so she calls her doctor s office. Mrs. Smith says, My pharmacy is charging me more money. I can t take my medicines any more
18 Mrs. Smith s Current Medication Regimen Drug Name Full Drug Initial Gap Catastrophic Cymbalta $369 $41 $175 $18 Advair HFA 115/21 $271 $41 $129 $14 Lantus $138 $41 $66 $7 Novolog $149 $41 $71 $7 Proair HFA $48 $41 $23 $7 atorvastatin $16 $7 $13 $7 omeprazole $11 $7 $9 $7 metformin $9 $5 $7 $3 lisinopril $7 $5 $5 $3 amlodipine $7 $5 $5 $3 Monthly Total $1,025 $234 $503 $76
19 Mrs. Smith s -Effective Regimen Drug Name Full Drug Initial Gap Catastrophic citalopram $8 $5 $6 $3 Flovent Diskus 250 $162 $41 $77 $8 Relion NPH $0* $25 $25 $25 Novolog $149 $41 $71 $7 Proair HFA $48 $41 $23 $7 atorvastatin $16 $7 $13 $7 omeprazole $11 $7 $9 $7 metformin $9 $5 $7 $3 lisinopril $7 $5 $5 $3 amlodipine $7 $5 $5 $3 Monthly Total $417 $182 $241 $73 * NOT submitted through insurance
20 Medication Savings Mrs. Smith Current Regimen (Annual ) New Regimen (Annual ) Annual Savings $3,094 $2,420 $674 Part D Plan Current Regimen (Annual ) New Regimen (Annual ) Annual Savings $7,118 $2,080 $5,038
21 CMS Star Ratings CMS initiative to improve quality, safety and efficiency of services beneficiaries receive Rating of 1 to 5 stars on various measures for Medicare Part C and D 20 operational measures 27 clinical measures Star ratings impact: Reimbursement/Capitation Ability to share in quality bonuses with stakeholders hospitals, clinics, pharmacies Retention and attraction of beneficiaries
22 New 2015 Star Measure: Comprehensive Medication Review Comprehensive medication review (CMR) Evaluate medication regimen for efficacy, safety, and costs Recommend treatment alternatives to providers Provide patient education Measures % eligible patients receiving CMR Patients who opt-out or do not respond to offers will not be excluded Challenges in providing CMR High patient and physician refusal rates
23 University of Michigan Health System
24 PCMH Pharmacist Practice Model 9 embedded pharmacists across all primary care sites 3.8 clinical FTE 9 internal medicine and 5 family medicine sites Provide disease management services (diabetes, hypertension, and hyperlipidemia) and CMR Pharmacist s time at primary care sites 1 6 half-days/week Scheduled patient appointments Clinic visits (30 minutes) Phone consults (15 30 minutes)
25 Pharmacist s Scope of Services Per Collaborative Practice Agreement Evaluate and optimize therapeutic regimen Provide medication management to achieve goals Assess and address barriers to medication adherence including costs Provide chronic condition education and medications Assist in limited physical assessment (BP, foot exam) Order labs and medical equipment (glucometer) Facilitate referrals to other health care providers Motivational interviewing for self management goals
26 Pharmacists Therapeutic Interventions Total: 2,674 interventions (5/1/11 4/30/12) increased dose added medication decreased dose deleted medication optimized regimen
27 Future Expansion Expand CMR and disease management services to specialty areas: Cardiology Psychiatry Chronic Kidney Disease Clinic Develop new reimbursement model to support CMR activities Reimbursement from Part D plans
28 Summary: Meeting Triple Aim Improve the experience of care Provide patient-centered care to address medication barriers and adherence Mrs. Smith is very happy with the care! Improve health Assess appropriateness of medications based on efficacy and safety to ensure optimal treatment plan Reduce cost of health care Decrease medication costs for patients and plans Prevent additional health care expenses due to discontinuation of necessary treatment
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