Transcript Document

Performance Enhancing Pharmaceuticals
Alan H. Heaton, BS (Pharm), Pharm. D., RPh.
Director of Pharmacy
BlueCrossBlueShield of Minnesota
Local Performance?
Percent change from previous year
Key Minnesota Health Care Cost and Economic Indicators
18%
16%
14%
12%
Health care cost
MN economy
Overall inflation
Workers' wages
10%
8%
6%
4%
2%
0%
1995 1996 1997 1998 1999 2000 2001 2002
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
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
JMCP. March 2003;9:Supp3.
American’s 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.
Nationally, Hyper Performance on Drugs
$3,000
16.0%
14.0%
$2,500
12.0%
9.9%
$2,000
10.4%
9.4%
10.0%
8.6%
7.6%
$1,500
4.9%
5.8%
12.0%
8.0%
6.1%
6.0%
$1,000
4.0%
$500
2.0%
$0
0.0%
1980
1990
1995
1998
Health Care Costs
Source: Health Care Financing Administration
1999
2000
2001 2002(e) 2005(e) 2010(e)
Pharmacy Costs as % of Health Care Costs
% of Health Care Cost
Total Health Care Costs ($ in Billions)
13.8%
Drivers of Drug Performance
Prescription costs are increasing annually at 14-21%
Trend Drivers
 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
Implications
 More users
 More prescriptions per user
 More expensive mix
 Higher unit costs
Utilization + Mix = 70% of Performance
Components of Prescription Drug Trend
Leveraging
Mix
10%
Price
Inflation
35%
20%
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
35%
Leveraging – erosion of effectiveness of
fixed cost-sharing over time
Utilization
Traditional employer cost management strategies have
not effectively addressed utilization and mix
1 Towers Perrin – “Employers, Prescription Drugs & PBMs”, 2003
Pharmaceutical Manufacturers
Comparison of Top 50 Drugs
Percent Change in Key Indicators
Contributing Most to One-Year Spending to All
Other Drugs and
Total Market (2000-01)
50%
43.3%
40%
31.7%
30%
17.1%
20%
10.1%
8.9%
10%
6.3%
6.7%
5.5%
1.1%
0%
Top 50
Rest of
M arket
Total
M arket
C HANGE IN SALES
Top 50
Rest of
M arket
Total
M arket
C HANGE IN UTILIZATIO N
Top 50
Rest of
M arket
Total
M arket
C HANGE IN AVERAGE
PRIC E
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.
Performance: Top 10 Drugs 2003
US sales in billions of dollars
•
•
•
•
•
•
•
•
•
•
Lipitor
Zocor
Prevacid
Procrit
Zyprexia
Epogen
Nexium
Zoloft
Celebrex
Neurontin
6.8
4.4
4.0
3.3
3.2
3.1
3.1
2.9
2.6
2.4
Current Performance
Members, Cost/Rx, Utilization and PMPM
By Age and Gender
70
180
M ($59)
F ($53)
140
50
F (584K)
120
F ($55)
Members
(1,129K)
40
M (545K)
PMPM
($48)
100
M ($40)
80
30
60
20
40
F (12.5)
10
Util
(10.3)
M (8.0)
20
0
0
0-4
5-9
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74
Age
75+
Total PMPM, $
Members, 1000s
Util, PMPY,
Cost/Rx, $,
160
Cost/Rx
($56)
60
The New Yorker, October 27, 2003
“We make a healthy difference in
people’s lives by utilizing pharmacy
benefits that feature access,
affordability, and appropriateness.”
Appropriate Therapy?
An estimated 44,000-98,000 people die
each year in hospitals because of medical
errors - Institute of Medicine report
57,000 people die each year because of
omission – they don’t benefit from known
therapies - NCQA
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
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
Measuring the Impact of
Collaborative Pharmaceutical Care
May 27, 2004
Study Architects:
Alan Heaton, BCBSM
Brian Isetts, College of Pharmacy
Dave Miller, Fairview/University Clinics
Wallace Wadd, Prime Therapeutics, Inc.
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)
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 DTP’s (10%) - drugs from friends and family
• 85% of patients had at least one problem
ECHO
• Economic outcomes
– Total health care costs
– Pharmacy costs
$481 to $411 pppm
$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)
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
Aligned Strategies: ROI
For every $1 spent on ACE Inhibitors, there was a decrease of over $6 on
hospital costs in patients with CHF
$12,000
$10,617
$10,000
$8,000
$6,000
$4,000
$2,000
$1,674
$0
3 Year Drug Therapy
Source: The SOLVD Investigators, NEJM 325(5):293-302, 1991
Hospital Costs Avoided
Integration and Simplification
One 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
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
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
Formulary Performance:
Value-Based Purchasing
• Value-based purchasing represents an attempt to
create incentives that reward quality and costeffective care
• Examples:
– Oregon rx drug initiative – evaluate which drugs are the
most effective within each class
– MN DHS MA DFC-PDL
Brand/Generic Cost
Cost Per Rx
$95.71
$100
$89.65
$90
$80.00
$74.68
$80 $70.68
$70
$60
$50
$40
$30
$20
$12.83
$14.29
$16.70
$18.33
$19.10
$10
$0
1999
2000
Brand
2001
2002
Generic
6 m o 2003
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
Total PMPM Trend 2000-2003
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.
35%
30%
25%
20%
15%
12.1%
9.5%
10%
9.1%
9.0%
7.1%
6.6%
5%
0.9%
1.3%
April
May
2.2%
0.5%
0.2%
Jul
Aug
-0.1%
0%
Jan
Feb
Mar
Jun
Sep
Oct
Nov
2002
3Q YTD 2003
-5%
2000
2001
Dec
Biotech, Specialty Products
Skin Disorders
4.1%
Respiratory Disorders
5.1%
Neurologic Disorders
5.9%
Infectious Diseases
12.7%
Heart Disease
4.1%
Digestive Disorders
4.6%
Diabetes
2.7%
Cancer
Autoimmune Disorders
AIDS/HIV
48.1%
7.0%
5.7%