Transcript No Slide Title - Express Scripts

Generics…
What do consumers think?
What do consumers do?
Emily Cox, PhD
Express Scripts
William Shrank, M.D., M.S.H.S.
Harvard Medical School and
Division of Pharmacoepidemiology and Pharmacoeconomics
Brigham and Women’s Hospital
Generics Vastly Underutilized
In Many Therapy Classes
2
Generics Vastly Underutilized
In Many Therapy Classes
Source: ESI Internal Research
3
$20 Billion in Potential Savings
2007 GFR
Actual
2007 GFR
Potential
Contraceptives
63.3%
90.0%
$405,622
Antidiabetics
55.1%
60.0%
$593,507
Beta Blockers
76.8%
89.0%
$495,529
Antihypertensives
58.9%
83.0%
$2,340,994
Antihyperlipidemics
37.9%
80.0%
$4,584,257
Antihistamines
55.3%
95.0%
$491,420
Systemic/Topical Nasal Products
46.4%
90.0%
$474,027
GI medications
38.6%
95.0%
$5,659,682
Antidepressants
66.8%
88.0%
$2,680,876
Antipsychotics
26.7%
30.0%
$123,636
Hypnotics
47.9%
70.0%
$559,912
Narcotic Analgesics
95.5%
97.0%
$259,043
Anticonvulsant
51.6%
73.0%
$1,421,268
Therapy Category
Source: ESI Internal Research
Potential Savings
($000s)
4
$20 Billion in Potential Savings
2007 GFR
Actual
2007 GFR
Potential
Contraceptives
63.3%
90.0%
$405,622
Antidiabetics
55.1%
60.0%
$593,507
Beta Blockers
76.8%
89.0%
$495,529
Systemic/Topical Nasal Products
46.4%
90.0%
$474
GI medications
38.6%
95.0%
$5,659,682
Antidepressants
66.8%
88.0%
$2,680,876
Antipsychotics
26.7%
30.0%
$123,636
Hypnotics
47.9%
70.0%
$559,912
Narcotic Analgesics
95.5%
97.0%
$259,043
Anticonvulsant
51.6%
73.0%
$1,421,268
Therapy Category
Potential Savings
($000s)
58.9%
83.0% insured
$2,340,994
• $20B for 157M commercially
Antihyperlipidemics
37.9%
80.0%
$4,584,257
• More than double55.3%
across95.0%
entire US$491,420
Antihistamines
Antihypertensives
5
Generic Pipeline is Strong
More than $65 billion within the next five years
Annual Sales $ Billion
$13.1 Other $10.3
Billion
Billion
$13.7
Billion
$9.1
Billion
$19.6
Billion
Other
Other
Depakote
Imitrex
Fosamax
Lamictal
Risperdal
Other
Flomax
Other
Cozaar/Hyzaar
Adderall XR
Effexor XR
Valtrex
Topamax
Prevacid
Lipitor
Diovan/HCT
Other
Levaquin
Zyprexa
Protonix
Actos
Lexapro
Seroquel
Singulair
Plavix
Increased Rate of
Compliance with Generics
Formulary status of the initial prescription
Nonpreferred Brand
52%
Preferred Brand
57%
Generic
40%
59%
45%
50%
55%
60%
Percent of Days Covered
Source: Shrank WH et al., Arch Intern Med. 2006;166:332-337.
7
Historic Levers
to Get to Generics
• Benefit design
– Tiered copayments
– Step Therapy
Effect of Brand/Generic Copay Differentials
$11 to $15
$16 to $20
$21 +
• Education and
engagement
Effect of Consistently Framed Messaging
Formulary
change only
1.9
2.9
5.2
0
1
2
3
4
5
Absolute increase in GFR relative to $0-$10
Source: Mager & Cox. AJMC 2007
+ framed
messages
retail /
mail rxs
retail rxs
Consistently framed
messaging
doubled and
tripled effect of
formulary change
alone
mail rxs
0% 10% 20% 30% 40% 50%
Fraction switching to lower-cost option
Source: ESI Research
8
How We Communicate About
Prescriptions to Consumers
• Effectiveness – does it work?
• Safety – what are the negative effects?
• Cost – how much will it cost?
Do beliefs along these dimensions
drive generic utilization?
9
Disease
Symptoms
Provider
relationship
Provider
preference
Illness
insight
Impulse
Barriers to
care
75
70
65
Belief in
benefit of
Rx
60
How do
people
really
decide?
55
Need for
medical
follow-up
Cost of Rx
50
Brand
image
45
Side
effects
Generic Fill Rate
Complexity
of
treatment
plan
80
We asked what they thought.
We measured what they did.
We Asked What They Thought
We Measured What They Did
Methods
• Random sample of 2500 adult prescription utilizers across
Express Scripts book of business
• February through April 2007: mailed survey to patients in
all 50 states and DC
Results
• 1,047 responses
• 48% response rate
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Are Generics Safer
and More Effective?
No Clear Advantage for Brands
Generics and brands with
relatively little difference
Percentage who agree
13
No Clear Advantage for Brands
Generics clearly
the winner on
issues of cost
Percentage who agree
14
So Why Doesn’t Everyone
Prefer Generics?
Percentage who agree
15
So Why Doesn’t Everyone
Prefer Generics?
Percentage who agree
16
Various Paths to a Prescription
Negotiated Discount/Rebate for Drugs
Negotiated Discount/Rebate
for Drugs (volume, market
share, formulary placement)
Chargeback
Drug Manufacturer
WAC-based
Payment Subject
to Prompt Pay/
Other Terms
Drugs
2
1
Negotiated Discount/Rebate for
Drugs (volume, market share)
Wholesaler
Drugs
AWP- or WAC-based
Negotiated Payment
Pharmacy Benefit Manager
Payment
Share of Rebates
from Manufacturer
3
WAC-based
Payment
Drugs
Pharmacy
WAC-based
Payment
Drugs
ASP-, AWP- or WAC-based
Negotiated Payment
Provider (hospital, physician)
Drugs
Health Plan/Payer
Premium
Flow of Funds
Cost Sharing/
Payment
4
Beneficiary
Flow of Prescription Drugs
AMCP Guide to Pharmaceutical Payment Methods, www.AMCP.org
Cost Sharing/
Payment
Physicians Unaware
of Pharmacy Coverage
Shrank et al. AJMC, 2005
Physicians Don’t Feel Accountable
“Doctor, who should talk
with your patients about
lower cost Rx choices?”
Shrank et al. AJMC, 2005
“Do You Talk With Your Doctors
About Drug Costs?”
Most patients never talk to
their doctors about drug costs
Shrank et al, Journal General Internal Medicine. 2006
Comfort Does Not Drive Behavior
I'm comfortable asking my physician to
substitute with a generic
67%
I'm comfortable asking my pharmacist
to substitute with a generic
61%
I ask my pharmacist about generics
I ask my physician about generics
My pharmacist asks me
My physician asks me
0%
25%
50%
75%
21
Comfort Does Not Drive Behavior
I'm comfortable asking my physician to
substitute with a generic
67%
I'm comfortable asking my pharmacist
to substitute with a generic
61%
I ask my pharmacist about generics
34%
I ask my physician about generics
33%
My pharmacist asks me
My physician asks me
0%
25%
50%
75%
22
Comfort Does Not Drive Behavior
I'm comfortable asking my physician to
substitute with a generic
67%
I'm comfortable asking my pharmacist
to substitute with a generic
61%
I ask my pharmacist about generics
34%
I ask my physician about generics
33%
24%
My pharmacist asks me
19%
My physician asks me
0%
25%
50%
75%
23
Divergence of Opinions
Regarding “The Rules”
Pharmacist can guide switching
31%
59%
Gvmt should require Medicare
patients to try generics first
37%
Private insurers should create
rules: try generics first
37%
44%
42%
Healthcare companies should
create rules
0%
Agree
31%
42%
20%
40%
60%
Disagree
24
Comfort with Substitution And
Communicating With Providers
Health-Belief Scale
GFR
Change
1. General preferences for generic drugs
2.3
0.23
2. Perceptions about generic safety and efficacy
2.8
0.106
3. Perceptions about generics value and costs
1.0
0.948
4. Comfort with generic substitution
4.9
0.021
5. Communication with providers about generics
3.8
0.012
Each model controls for patient for age, gender, self-described health, income, education, benefit design,
and benefit generosity. Parameter estimates reflect the increase in the proportion of generics used for each
standard deviation increase in response for each factor. Higher scores in each factor indicate more positive
views regarding the factor domain. * p value < 0.05, ** p value < 0.001, *** p value < 0.001
P
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Patient Variation in Preferences
“Generics are a better value”
• Women 1.47 x more likely to agree
“Generics are safer than branded drugs”
• Highest income 6 x more likely than lowest income to agree
“Americans should use more generics”
• More educated patients are more likely to agree
“I prefer to use generics”
• Wealthiest patients most likely to agree
What Did We Learn?
• Attitudes toward generics
– Generics are less costly – they ‘get it’
– Generics are no worse than or better than brands
– On the whole – generics are better value
• Gaps in communication around generics
• Process stronger driver of generics
– Comfort with generic substitution
– Dialogue with “the experts”
27
Intuition is not Enough
• One size does not fit all
• Research questions
– Do patients view brands a status symbol?
– Does different framing of generics (i.e., tried
and true) impact use?
– Which framing is most impactful across
segments?
• Rigorous testing will be our focus going
forward