Transcript The Oregon Preferred Drug List: Evidence

The Oregon Preferred Drug
List: Evidence-Based
Medicine Meets Political
Reality
Beth Houghton
John Pedey-Braswell
Susan Williams
Patricia Wu
Objectives
• Background on the Oregon Fiscal Crisis.
• As a class explore ideas for creating a preferred
drug list.
• Explore implications for stakeholders.
• Overview of Drug List and how it works.
• Politics involved.
• Why this is important.
Background
• $2 billion deficit in 2002.
• 8.2% unemployment – now 7.2% but most of
the new jobs are low-wage without insurance.
• Voters refuse to pass budget tax increase
Measure 28.
• Emergency increase passed by legislature;
threatened by “Eyman-like” referendum (vote
2/04).
Start the Saws and Make Some Cuts.
• Shorten K-12 School Year.
• Slash funding to public universities and
community colleges. Tuition increases.
• Lay-off state troopers.
• Close crime labs.
• Trim prosecutor’s office work week to 4 days –
stop prosecuting non-person offenses.
• Close 4 Youth Prisons.
How Low Can You Go?
• Reduce eligibility of Oregon Health Plan (OHP)
to 65,000 persons from 100,000.
• End state-subsidy of methadone clinics.
• Loot tobacco fund – eliminate “quit line” and
school prevention education programs.
• Close Layne County Psychiatric Hospital, and
transitional program at State Hospital in Salem.
• Eliminate outpatient psychiatric services from
OHP – 10,450 patients without treatment.
A Preferred Drug List Might Help
• What kind of list would you create? (5-10
suggestions?)
• What is likely to make the biggest impact?
• How do you implement your plan?
• Which stakeholders are likely to be impacted by
your proposal – why?
Consider?
• Callers and faxes swamp Washington DSHS prior-authorization
lines for exemption to OxyContin restrictions – 1600/day during
first weeks of November 2003. (Seattle Times 12/11/2003)
• Kentucky Medicaid proposed excluding Zyprexa® from
formulary to shrink $230 million deficit. Eli Lilly pays to send
National Alliance for the Mentally Ill and Kentucky Consumer
Advocate Network members to protest in Frankfort, and pays
for advertisement attacking plan in state newspapers. (New York
Times 12/18/2003)
Oregon Medicaid: PMPDP
• PMDPD – Physician Managed Prescription Drug
Plan
• PDL based upon:
– clinical evidence (Oregon EPC)
– prescription drug cost
• Prescriber use of PDL is voluntary; physicians must
be educated about the PDL
• Stakeholder contribution
• Collaboration with other Medicaid programs
PMPDP: Stakeholder Concerns
• Only RCTs considered – PDL too restrictive
• When clinical evidence is lacking, cost of drug
should not be the determining factor
• Physician education is not cost-effective
• What is the true impact on patient health and
physician prescribing habits?
Oregon’s PMPDP
• Identify most effective drugs in a cost effective
manner
• Most costly med  Most effective med
– Rofecoxib not more effective than naproxen
• Preferred Drug List – 25 classes of drugs
• Evidenced-based evaluations
• Cost considerations are secondary
PDL process
• 25 MD’s
• Subcommittee- practitioners and interested
citizens
• Oregon Health and Science University’s
Evidence-based Practice Center
• Pharmaceutical Companies
Statins
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Atorvastatin
Fluvastatin and ER
Lovastatin and ER
Pravastatin
Simvastatin
Rosuvastatin
Statin Considerations
• LDL lowering comparisons
•  Risk of MI, CHD, stroke, mortality
comparisons
• Is  LDL  to improved clinical outcomes?
• Differences in demographic groups?
• Differences in safety with special populations?
Statin Info
• 67 RCTs
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HPS
ASCOT-LLA
ALLHAT-LLC
PROSPER
LIPS
• 4 dossiers from pharmaceutical companies
OR PDL Statins
• Lovastatin (benchmark)
• Pravachol
Conclusion
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Oregon fiscal crisis
Create a preferred drug list
Stakeholders
Overview of preferred drug list
How preferred drug list works
Politics involved
Why is this important?