Health Plans and the Role of Physicians, Pharmacists

HEALTH INSURANCE PREMIUMS have been increasing at two to five times the rate of inflation for the past decade. We know the two primary inflationary drivers in health care are the cost of hospital services and pharmaceutical products. We also know 5 percent or fewer beneficiaries generate approximately 60 percent of costs for any given health plan.

Health plans across the country are becoming proactive in their support for individual beneficiaries at risk for developing catastrophic complications as a result of their chronic illnesses.

Physician and pharmacist consultants are being retained to work with health plans. These professionals are inventorying, stratifying and strategically targeting medical risk within the health plan. In addition, they are determining the adequacies of the therapy at-risk beneficiaries are receiving based on national "best practice" data.

There are a number of important issues consulting physicians and pharmacists focus on when retained by the health plan to proactively serve beneficiaries. Some of the issues are:

• Chronic disease patients take many medications. Multiple drugs increase the risk of drug interactions that can lead to avoidable catastrophic consequences.
• Beneficiaries frequently do not receive the medications that are indicated for their condition.
• Beneficiaries frequently use brand products where high quality generic alternatives are recommended.

Drug interactions
Beneficiaries with chronic illnesses generally receive multiple prescriptions, and are at risk for drug interactions. For example, patients who consume 2-5 drugs daily have a 19 percent incidence of potential drug interaction. This risk rises to over 80 percent for those taking six or more drugs. Kidney or liver impairment along with age may affect the patients' ability to eliminate drugs from their system and thus increase the risk of drug interactions even further.

Beneficiaries who suffer from chronic illnesses also use multiple (non-prescription) over-the-counter products (OTC). OTC drugs frequently contain the same active ingredients. Many of these agents are known to interact with prescription compounds.

In addition, a recent Institute of Medicine report, sponsored by the Food and Drug Administration (FDA), estimated that Americans spend close to $16 billion each year on dietary supplements, which includes vitamins, minerals, herbs, and other plant-derived substances. Most of these products can generate drug interactions.

Just because a product is herbal doesn't mean it's safe. The American Academy of Family Physicians says Ginkgo biloba can cause potential problems if used with aspirin, warfarin, and other drugs; St. John's wort should not be used with an antidepressant; and ephedra can cause problems if used with a decongestant or a stimulant drug, or even caffeine.

Consulting physicians and pharmacists evaluate the incidence of serious illness in health plans using medical and pharmacy paid claims data analysis. These analyses identify individual beneficiaries likely to have developed drug interactions or are at risk for doing so in the future. Health plans then offer, at no charge to the beneficiary, a consultation with a pharmacist.

This consultation includes identifying all of the prescription, OTC and supplement products that the beneficiary may be using. If there is evidence of a risk for drug interactions, the pharmacist consults with the beneficiary's physician to eliminate or minimize the risk.

Inadequate treatment of chronic disease
A recently published Rand Corporation Study¹ found that patients with chronic illnesses in the United States receive substandard health care about half of the time. An in-house analysis at our new firm, Illumination, supports this data. Some examples of inadequate therapy we have identified include:

Over a 12-month period, fewer than 55 percent of beneficiaries with atrial fibrillation had prescriptions filled for an anti-coagulating agent (coumadin or warfarin).

Fewer than 71 percent of beneficiaries with Congestive Heart Failure had prescriptions filled for an angiotensin converting enzyme (ACE) inhibitor.

None of the beneficiaries with history of myocardial infarction were on beta-blockers. Beta blocker treatment in MI survivors reduces mortality by 40 percent in patients older than 60 years of age, and 28 percent in younger patients.

There are many reasons why beneficiaries with chronic disease have treatment histories that are not consistent with nationally accepted guidelines. The most frequent cause we identified involves patient non-compliance with the advice given by their physician.

Approximately 50 percent of medications written for chronic disease states are never picked up by the patient, while over 66 percent of patients fail to comply with their doctors' overall treatment recommendations .²

Non-compliance is the leading cause of failed medical treatment in clinical practice. It generates 10 percent of all hospital admissions and almost 30 percent of admissions to nursing homes. Noncompliance is estimated to cause over $100 billion per year in unnecessary medical spending in the United States.³

Unfortunately, attending physicians have no feed-back loop to alert them to patient noncompliance. They assume, mistakenly, that once a prescription is written, the patient will obtain the drug and begin using it.

Working together, consulting physicians and consulting pharmacists can now monitor the disease state of beneficiaries and determine when prescribed products have actually been paid for by tracking paid medical and pharmacy claims. Armed with this data, the pharmacist can determine why compliance is a problem and alert the patient's physician.

The pharmacist can also work with the health plan if the patient's financial status precludes obtaining a prescription - which is of increasing importance as health plans move to higher deductibles and- co-payments.

Use of brand vs. generic products
Physicians frequently prescribe newer, more expensive drugs for chronic illnesses instead of the generic alternatives recommended under "best practice guidelines." For example, a recent study found that 40 percent of the time patients were prescribed non-protocol drugs, generally brand name products. It was estimated that $1.2 billion a year could have been saved if physicians prescribed within protocol for high blood pressure medicine alone.⁴

There are many causes for prescribing patterns that favor more expensive brand name products. Aggressive drug-company advertising along with a patients belief that the best care is the costliest tends to drive the preference for brand prescribing.

Current research demonstrates that prescribing within protocol using generics where appropriate can significantly reduce the cost for the pharmacy benefit without compromising patient care.

Conclusion
Health plans have relied on traditional benefit consultants and actuaries to advise the plan's administration concerning benefit design, rate setting and reserve requirements. Unfortunately, this experience-based, financial approach to plan management has delivered inflationary trends that are consistently 3 to 5 times the overall rate of inflation.

Health plans are now adding medical consultant advisors to their administrative infrastructure. These consulting physicians and pharmacists focus on the evolving medical liabilities facing their health plan client.

The pharmacy lies at the core of quality health care today; and the inflationary trend for the pharmacy benefit is not sustainable. That means the inclusion of a pharmacist in the consulting support for a health plan is indispensable for the future.

davidjgibson@email.msn.com

1. Eva A. Kerr, Elizabeth McGlynn, at al. "Profiling the Quality of Care in Twelve Communities: Results from the CQI Study," Health Affairs, May/June 2004.
2. Task Force for Compliance. Noncompliance with Medications: An Economic Tragedy with Important Implications for Health Care Reform, A Report of the Task Force for Compliance. April, 1994.
3. National Pharmaceutical Council. Noncompliance with medication regimens: An economic tragedy. Emerging Issues in Pharmaceutical Cost Containing, 1992; 2; 2: 1-16.
4. JAMA. 2004;291:1850-1856. http://jama.amaassn.org/cgi/content/abstract/291/15/1850