Reprinted from DRUG BENEFIT NEWS, biweekly news, proven cost management strategies and unique data for health plans, PBMs, pharma companies and employers.
By Lauren Flynn Kelly, Editor
April 12, 2013 Volume 14 Issue 7
As CMS continues to place emphasis on medication adherence in its star quality ratings for Medicare Part D plan sponsors, plans that employ an integrated strategy with their PBMs are at an advantage when it comes to boosting adherence, suggested executives from Florida Blue and Blues plan-owned PBM Prime Therapeutics LLC during a recent AIS webinar. Drawing on lessons learned from their own combined experience, speakers advised using targeted and well-timed outreach and communication methods while watching out for barriers to adherence such as cost and patient misconceptions about their medications.
Medicare Part D plans are rated in four domains, which include drug pricing and patient safety. There are four measures related to medication adherence for hypertension, diabetes, high cholesterol and, as of 2013, HIV. Starting in 2012, adherence measures were weighted three times as much as star measures in the other domains, comprising almost half of the aggregate score in general. “So you can see there’s a tremendous amount of focus on adherence measures because of that weighting and the impact to plan sponsors,” explained David Lassen, Pharm.D., chief clinical officer at Prime, speaking at the March 28 AIS webinar, “Medicare Star Ratings: An Integrated Approach to Improving Medication Adherence Measures.”
Based on their experience working together to improve adherence measures, Florida Blue and Prime recommended incorporating the following four elements into an integrated strategy:
(1) Utilize a “joint dashboard” or similarly shared tool to continuously evaluate the measurements and assess the impact of various interventions.
(2) Review on an ongoing basis the communications between all parties involved in supporting the star rating measures.
(3) Conduct pilots and proof of concepts to test and measure more targeted interventions, moving away from a “one-size-fits-all approach,” and determine if there’s something worth rolling out on a broader basis.
(4) Constantly refine engagement activities, comparing and benchmarking various activities (e.g., mail campaigns, automated refill reminder programs) across the board.
When it comes to outreach methods, Cynthia Griffin, Pharm.D., senior director of pharmacy government programs at Florida Blue, advised that both timing and coordination are critical to impacting overall adherence. “I think we’ve learned in health plans over time, the best approach appears to be a holistic one in which the outreach efforts are focused on addressing multiple care gaps with fewer communications,” she observed. “[Members] don’t want to be bombarded with mass communications from their health plans or various vendors representing their health plans.”
In a telephone-based refill reminder pilot conducted in conjunction with Prime, Florida Blue targeted 17,000 members during a 30-day period to ask patients why they are likely to skip a drug. For those who were taking a single drug, 30% responded that they felt they didn’t need the drug. But for patients taking multiple medications, cost replaced “don’t need” as the No. 1 answer (33% versus 25%). The next phase of Prime and Florida Blue’s collaboration will include tailoring interventions based on patient preference and performing a “deeper drill-down” into that “don’t need” category, said Griffin.
Experts Warn Against Free Generic Programs
When discussing the impact of pharmacy benefit design on medication adherence, Lassen pointed out that members utilizing free or $4 generic drug discount programs offered by retailers have the potential to skew data when it comes to tracking adherence. A Prime study released last year was the first to quantify the impact of such programs on a PBM’s ability to conduct and monitor clinical programs (DBN 5/11/12, p. 1).
“We know that member cost-share does have a significant impact on adherence…and the impact of managing generics in this space is also very significant,” he observed. But “ensuring the generic copay for drugs in the star rating adherence measures are at or below common $4 generic cut-points helps otherwise the shifting in members to free generics, which can cause potentially the member to not use their insurance card for processing the prescription and impact the overall star rating measures negatively.” For plans that are considering offering free generic programs of their own, Lassen recommended they “use a targeted approach targeting those [drugs] with star rating measures.”
“Within a given population or region there can be considerable utilization of these programs, and I think the challenge for us as plans is when members vary utilization from month to month,” added Griffin. In other words, a patient may utilize his or her prescription drug benefit one month, and then use one of the free drug programs the next month, leading the plan to view the member as nonadherent. Therefore, it may be necessary to engage case managers and plan pharmacists to work through the process of determining a patient’s overall adherence pattern, she suggested. “And I think it’s really key to engage the member through your overall educational process so that they will understand the impact of various practices.”
Suspecting that such programs were impacting the insurer’s ability to track and manage adherence, Blue Cross & Blue Shield of Rhode Island conducted an internal analysis to determine that fewer claims were being lost than expected. “It was a little less, but not dramatically less,” says Tara Higgins, R.Ph., clinical pharmacist, who did not speak at the webinar. She explains to DBN that the majority of the Rhode Island Blues plan’s pharmacy contracts employ a “lower of” logic, so if a patient goes into a Walmart and shows his or her insurance card, the member will walk out paying the lower of either the copay amount or the pharmacy’s amount, which is typically $4 for popular generic drugs sold at big-box retailers. Because of the way those contracts are written, the claim would still be captured by the health plan as long as the member presented his or her insurance card.
“I’ve talked to friends that work in the retail setting and I’ve asked them if they ask for the insurance card and they said yes,” reveals Higgins. “The thing that happens is patients believe that they’re not eligible for the program if they present their card. So we have an opportunity to educate members and explain that they’re still eligible for these programs and it’s important for the capturing of the information from a safety perspective [to present the card].”
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