A host of new studies with implications for payers and other healthcare stakeholders were presented at the 2010 Annual Meeting of the Academy of Managed Care Pharmacy (AMCP) in April in San Diego, CA. The following summaries highlight some of the major trends presented at the meeting.
Patient Out-of-Pocket Cost Affects Adherence to Oral Oncology Medications
Increasing out-of-pocket (OOP) cost to health plan members above a certain threshold reduces adherence to cancer medications, suggested researchers from Prime Therapeutics, Eagan, MN. Pat Gleason, PharmD, Director of Clinical Outcomes Assessment at Prime Therapeutics, and colleagues analyzed data from a database of 7 million Blue Cross and Blue Shield members in the Midwest and South who were prescribed oral drugs for cancer for the first time between July 2006 and June 2008.
Based on their OOP cost, patients were divided into 4 groups—$0 to $100, $101 to $200, $201 to $500, and >$500. Patients with OOP cost >$200 were 3 times more likely than those with lower OOP cost to stop their drug therapy.
During the study period, of the 1909 members who started therapy with oral oncology medications, 163 (8.5%) stopped taking their drugs. Although 1562 (81.8%) of those patients had an OOP cost of $0 to $100, the next largest group (14%) had a cost-sharing (OOP) >$500. Those with an OOP cost between $201 and >$500 were 3 times more likely to stop their therapy than patients in the lower 2 groups. “The $200-plus group is where things start to change," said Dr Gleason. The therapy discontinuation rate was 16.1% for those in the $201 to $500 OOP group and 28.8% for the >$500 OOP group.
Age and sex were not associated with the level of medication adherence.
Cost-Effectiveness Trends for 20 Top-Selling Drugs
With increasing healthcare costs and budgetary pressures, payers are focusing on superior efficacy and costeffectiveness as determinants for medication coverage. The new emphasis on comparative effectiveness research (CER) and the growing focus on cost-effectiveness research in the past 10 and 15 years are further indications that performance and pricing will increasingly determine drug utilization and reimbursement. A team of researchers from PAREXEL Consulting, Waltham, MA, led by Saurabh Agarwal, PhD, investigated the current trends of cost-effectiveness studies for the 20 top-selling drugs worldwide—which collectively generated between $150 billion and $160 billion in worldwide sales in 2008— to see whether these studies can indeed offer the information payers are seeking in their coverage decisions.
The study results showed that despite the growing focus on CER and cost-effectiveness studies, those conducting the research use various methodologies and models that do not coincide, which may impede reaching the conclusions necessary for true comparative research. The team analyzed peer-reviewed cost-effectiveness studies published between 1999 and 2008, collecting data on the comparator drugs used in each study, the indication, the incremental cost-effectiveness ratio (ICER), length of study, and the model used, in addition to other study characteristics.
The researchers found a large variability in methodology used by the different groups in modeling costeffectiveness related to the same drugs, especially in terms of study duration and a comparator drug, for different indications, as well as for the same indications. Different groups selected different comparator drugs, applied different treatment costs in their assessments, and used different time projections for costs, all of which made outcome comparisons difficult.
Primary care drugs had less variability than specialty drugs. Among the 10 top-selling drugs, quetiapine and erythropoietin had the highest variability in study methodologies and ICER. In contrast, atorvastatin, salmeterol/ fluticasone, and clopidogrel had the most consistent ICER values across the studies.
Effect of Diabetes Medication Adherence on Costs and Outcomes
Diabetes is among the key drivers of healthcare costs in the United States, and the prevalence of the disease continues to rise. A team of researchers from Blue Cross and Blue Shield of Nebraska and the University of Nebraska Medical Center investigated the impact of medication adherence and following clinical guidelines on the cost of type 2 diabetes, visits to emergency departments, and hospitalizations.
Using pharmacy and medical claims data, 5573 adult members with type 2 diabetes who were continuously enrolled in a Midwestern managed care health plan from January 1, 2008, to December 31, 2009, were enrolled in this study. A total of 4480 members met the criteria for medical guidelines (screening for hemoglobin [Hb] A1c, lipid panel, cholesterol, and hypertension) in 2008, and 4683 members met the criteria in 2009. Medication adherence was measured by medication possession ratio.
Increased medication adherence resulted in a significant trend toward reduced total, professional, and facility costs for all drug classes—except for statins and sulfonylureas—even though pharmacy costs increased.
Adherence to HbA1c testing reduced emergency department visits during the study period. Inpatient admission trended down from 2008 to 2009 with adherence to cholesterol and lipid testing. In 2009, patients adherent with all of these types of testing had significantly lower costs than nonadherent patients.
Applying Pharmacogenomics in Oncology Care
Pharmacogenomics is the study of genetic influences on variations in patients’ response to drug therapy (a variation of personalized medicine). To date, no studies have looked at the application of pharmacogenomics in oncology drug utilization. Researchers from CVS Caremark, Northbrook, IL, presented data on the frequency and utilization of pharmacogenomics to determine the appropriateness of oncology treatment within a utilization management (UM) program.
Using pharmacogenomic testing data from July 1, 2009, through December 31, 2009, a total of 801 patients who had such data were categorized into 3 groups, based on UM criteria developed using US Food and Drug Administration–approved and compendiabased indications for cancer therapies:
- Pharmacogenomic testing performed and patient met UM criteria
- Pharmacogenomic testing performed and patient did not meet UM criteria
- Pharmacogenomic testing not performed and patient did not meet UM criteria.
Of these 801 patients, 424 patients required pharmacogenomic testing, and 417 (98%) of them underwent testing. Lead researcher Sherry Siegert, PharmD, noted that having such a high percentage of patients receiving testing when needed "may indicate that most oncologists are prescribing in accordance with currently accepted guidelines."
Despite the small study sample and short duration, these findings suggest that payers can use UM practices to ensure appropriateness of therapy, such as requesting copies of pharmacogenomic test results and standardizing test requirements.
Applying pharmacogenomics is particularly important in cancer care, considering the cost of therapy and the serious implications of inappropriate therapy for this patient population.