Transcript Who`s Gambling with Your Health” – Dr. Evelyn Lewis, Consumer

High Stakes Healthcare: Who’s
Gambling With Your Health?
Evelyn L. Lewis, MD, MA, FAAFP
Deputy Director USU Center for Health
Disparity Research and Education
Medical Director Pfizer, Inc
Therapeutic Switching
Pay for Performance
What Everyone
Should Know
Objectives
1.
2.
3.
4.
Defining Drug Switching
Drug Switching Practices and Trends
Clinical Risks of Drug Switching
Other Considerations
DEFINING DRUG SWITCHING
Several Terms Are Commonly Used to
Refer to Drug Switching
Generic Substitution
Therapeutic Substitution
Substitution
Substitution
of a drug with the same
active ingredient and mechanism of
action, but produced by a different
manufacturer
Generic
Substitution
of a drug that treats the
same medical condition according to
guidelines outlined in a drug
formulary
The drug products have different
active ingredients and/or
mechanisms of action
One version, called therapeutic
interchange, requires the consent of
the prescribing physician
Therapeutic
Substitution
Drug Switching Affects Patients and
Physicians and Has the Potential to
Increase Overall Healthcare Costs
Patient Experience
 Increases likelihood
of poor clinical
outcomes
 Can hurt patient
experience
 Can particularly effect
vulnerable
populations
Healthcare Costs
 May drive additional
physician visits, tests
Drug Switching
 May create greater
Physician Experience
 Can interfere with MD
- patient relationship
 Can decrease ability
to provide
personalized care
need for acute care
̶
May raise overall
healthcare costs
Drug Switching Means That A Patient
Does Not Receive the Drug Originally
Prescribed by Their Physician
Generic
Substitution
Physician Prescribes:
Prozac
Therapeutic
Substitution
Patient Receives:
fluoxetine
Therapeutic
Substitution
Patient
Receives:
Zoloft
Generic
Substitution
Patient
Receives:
Sertraline
(Zoloft)
Generic Substitution Law - 2007
Permitted
Mandatory
Source: National Association of Boards of Pharmacy, “2007 Survey of Pharmacy Law”
Patient Consent
is Not Required
Patients Face Various Risks Depending
on the Type of Switching
Patient risk factors
age
health status
current medications
Tiered formulary, prior authorization, step therapy, generic substitution, therapeutic interchange
Patient receives
drug prescribed
Patient receives
generic version
Patient receives different
drug
Potential Consequences
Potential Consequences
Potential Consequences







Delayed access to
medications
Administrative burden for
patient, physician,
pharmacist

Adverse reaction to
substitute
Lack of patient awareness

Less risky
Decreased efficacy
Drug-drug interactions
Intolerable side effects
Adverse reaction to
substitute
Lack of patient awareness
More risky
DRUG SWITCHING PRACTICES
AND TRENDS
Public and Private Payers Are Using A Variety of
Approaches to Promote Drug Switching
Drug Switching Strategy
Definition
Example
Tiered Formulary
(differential costsharing)
Each formulary tier has higher cost
sharing to encourage patients to choose
lower priced drugs. Generics typically
have the lowest cost sharing requirement.
Patient goes to pharmacy for Prevacid but
told lansoprazole is cheaper. Patient
chooses Lansoprazole due to lower price.
Generic Substitution
Substitution of a generic product for a
branded drug with the same active
ingredient.
A patient goes to the pharmacy and
receives simvastatin (generic) instead of
Zocor (brand).
Therapeutic Interchange
Substitution of a drug with different active
ingredient for prescribed drug.
Patient gets prescription for Mobic
(meloxicam) but pharmacist dispenses
Toradol (ketorolac).
Prior Authorization
Requires a provider to provide clinical
justification in order to obtain permission
from payer to prescribe a medication.
Doctor prescribes Bevacizumab but must
first call patient’s health plan to obtain
permission.
Step Therapy
Requires use of one or more drugs in a
graduated manner before other drugs
used to treat the condition will be
covered.
Patient with psoriasis must take
methotrexate for 90 days before they can
be reimbursed for Humira.
Generics Only Policy
A plan only covers generic brands on
their formulary.
Patient gets prescription for Zyrtec but
insurance only covers generic, cetirizine.
Private Plans Are Using Financial Incentives and Other
Strategies to Support Drug Switching Programs
Strategy
Definition
Example
Pay for Performance (P4P):
Switching brand to generic
Physicians are financially rewarded
for prescribing drugs on a plan’s
formulary
BCBS of Michigan paid physicians $100
per patient switched from brand to a
generic statin1
P4P – Payment
Withholds/Physician “Risk
Pools”
Payer withholds portion of perpatient payment
If physician payment is $100 per patient,
insurer pays $80. The doctor receives the
remaining $20 only if related medical and
drug costs fall below a threshold value
P4P – Generic Utilization Rates
Doctors are rewarded financially for
prescribing generic drugs
Generic prescribing rate counts for 25%
of physicians’ total quality scores in
Anthem Quality Insights P4P program2;
up to 6% bonus payment
Promoting Formulary
Compliance
Payer or pharmacist attempts to
influence prescribing behavior
directly
Fax or call physicians to advocate
specific drug switches
Incentives for Pharmacists
Insurers reward pharmacists for
recommending formulary drugs
PCS Health Systems paid pharmacists up
to $12 per Rx to recommend specific
drugs3
In 2000, physicians filed largest healthcare class action suit against eight HMOs. Plaintiffs
alleged insurers denied claims based on cost alone. Defendants have since settled for more
than $1 billion.
The Vast Majority of Medicaid Programs Are
Using a Full Range of Mechanisms to Promote
Drug Switching
Frequency of Medicaid Drug Switching Approaches
2001 - 2008
100
Percetage of States
90
Prior Authorization
80
Generic Substitution
70
60
Preferred Drug List
50
40
30
20
10
0
2001
2002
2003
2004
2005
2006
2007
2008
Year
Source: Avalere Health analysis using DataFrame®, a proprietary database of Medicare Part D plan features. 2008 data from
November 2007; 2007 data from November 2006; 2006 data from July 2006.
Some Medicaid Programs Have Explicit Therapeutic
Interchange and Therapeutic Substitution Policies
State
Strategy
Description
Washington
Therapeutic
Interchange
Under Washington’s Therapeutic Interchange Program (TIP),
pharmacists must substitute a non-preferred drug with a preferred
drug for prescriptions written by Medicaid-participating physicians
who have endorsed the state’s PDL. Pharmacists must notify
physicians of the substitution within 24 hours; physicians can override
the substitution by writing “dispense as written” on the prescription.
Non-preferred drugs prescribed by non-endorsing physicians are still
subject to prior authorization.
Wisconsin
Therapeutic
Interchange
Pharmacists receive an enhanced dispensing fee if they contact a
Medicaid prescriber and the prescriber agrees to change a prescription
from a non-preferred drug to a preferred drug.
North
Carolina
Therapeutic
Interchange
and
Substitution
Medicaid recipients with more than 11 monthly prescriptions must
participate in the Focused Risk Management (FORM) program,
facilitated by the recipients’ pharmacists. Under FORM, pharmacists
perform a comprehensive drug regimen review to identify opportunities
for therapeutic interchange.
Source: State Medicaid websites
Drug Switching Can Lead to Poor Clinical
Outcomes and Higher Medical Utilization
Drug Switching Can Lead To:
1.
Less Effective Treatment
2.
Side Effects
3.
Drug Interactions
Poor Clinical
Outcomes
Higher Medical
Utilization
Clinical Implications of Drug Switching Are Particularly Severe
and Frequent In Certain Populations
Populations
Potential Problems
Patients with multiple
conditions

Increased risk of adverse events from taking
multiple medications1,2
Elderly patients

Age and disease-induced changes can affect
absorption, distribution, metabolism, and elimination
of medicines2
Likely to have multiple comorbidities (In 2002 50% of
Medicare beneficiaries had 5+ chronic conditions)2

Patients with certain conditions
(List of conditions is not
exhaustive)



Mental illness
HIV/AIDS
Alzheimer’s



Cancer
Epilepsy
Multiple Sclerosis
Sources: 1NAMI comment letter on Formulary Guidance, 2005; 2“Medication Use by Aged and Disabled Medicare Beneficiaries
Across the Spectrum of Morbidity: A Chartbook” The Peter Lamy Center on Drug Therapy and Aging, University of Maryland
School of Pharmacy, 2007.
OTHER CONSIDERATIONS
Drug Switching Practices: Often Not Transparent To
Patients and May Have Negative Impact on Their
Experience
Physician Prescribes
Medication
May not inform patient of
potential switches due to:
 Limited time with patient
 Lack of familiarity with
patient’s insurance plan
 May have undisclosed
financial incentive
Pharmacist Dispenses
Medication
May not inform patient of
switches due to:
 Limited time with patient
 Pharmacy or insurance
policies
Patient Uses Medication
Even when provided an
explanation, patients may
not understand reasons for
drug switch or differences
between medications
When asked by reporters if patients moved from Lipitor to generic Zocor were aware that
their physicians were paid $100 per patient switched, a spokeswoman for Blue Cross Blue
Shield of Michigan said, “not specifically.”
A former Lipitor patient’s response to the information?
“I’m shocked. They’re paying the doctors?”1
Source:1The Boston Channel, “Doctors Paid to Switch Patients to Generic Drugs,” August 1, 2007