Payers’ Perspective: Incorporating Real-World Evidence in Patient Care

April 2017 Vol 10, No 2 - Conference Correspondent, Conference Highlights AMCP
Lilly Ostrovsky
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The following summaries represent a sample of the many real-world, evidence-based studies presented at the 29th Annual Meeting of the Academy of Managed Care Pharmacy (AMCP), March 27-30, 2017, in Denver, CO

Hospitalizations and Emergency Department Visits High Among Patients with Parkinson’s Disease

Parkinson’s disease is a common neurodegenerative condition, affecting up to 1 million people in the United States. Although studies have shown that hospitalization rates and emergency department visits are high among patients with Parkinson’s disease, recent utilization estimates of these resources are scarce. However, the results of a new study presented at the 2017 AMCP meeting demonstrated that US hospitalizations and emergency department use are substantial among patients with Parkinson’s disease, accounting for more than 272,000 hospitalizations and more than 416,000 emergency department visits in 2014.

Using the 2014 Nationwide Emergency Department Sample, the National Inpatient Sample database, and the US Census Bureau, Alka Mithal, MD, ICORE, Woodside, CA, and colleagues identified 416,787 emergency department visits among patients with Parkinson’s disease in that sample, which translates to an incidence of 131 visits per 100,000 people in the US population. In total, 55.3% of these visits were attributed to men with Parkinson’s disease; furthermore, Parkinson’s disease was the secondary diagnosis in the majority of emergency department visits recorded.

Medicare paid for approximately 85% of all emergency department visits, whereas Medicaid only paid for approximately 4%, and private insurers paid for approximately 8% of emergency department visits.

In addition, although the highest rate of emergency department use was reported in patients aged 65 to 84 years, 14.5% of the visits were attributed to younger patients aged <65 years, suggesting that Parkinson’s disease may have a negative effect on work and productivity.

The study also showed that patients with Parkinson’s disease accounted for 272,450 hospitalizations in 2014, of which 57% occurred in men, and only 4.5% were attributed to primary diagnosis of Parkinson’s disease. As with emergency department visits, the prevalence of hospitalizations increased with age, and twice as many men aged ≥85 years were hospitalized as women. Similarly, Medicare paid for approximately 87% of hospitalizations, whereas Medicaid paid for only 3% of hospitalizations, and private insurers paid for 8% of hospitalizations.

Overall, approximately 12% of hospitalizations were reported in patients aged <65 years, similarly implying that Parkinson’s disease may lead to work loss and reduced productivity. This study shows the substantial impact of Parkinson’s disease on expensive healthcare resource utilization in the form of emergency department visits and hospitalizations.

[Source: Mithal A, Lingala B, Niyazov A, et al. Hospitalizations and emergency department visits in patients with Parkinson’s disease in the US: a national perspective.]

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Impact of Copay Assistance on Medication Adherence in Type 2 Diabetes

Adherence to drug therapy is paramount for favorable health outcomes, especially in chronic diseases such as type 2 diabetes. Multiple factors can contribute to medication nonadherence, one of which is expensive drugs; however, the effect of lowering drug costs on adherence to treatment has not been fully elucidated. Rachel Wiechert, Southern Illinois University Edwardsville School of Pharmacy, and colleagues examined the impact of a value-based benefit design program on medication adherence, drug utilization, and expenditures in patients with type 2 diabetes at Ascension Health, a large nonprofit health system.

This value-based program reduced the copayment rates for all antidiabetes drugs to $10, across all 3 formulary tiers, for employees and family members with type 2 diabetes who had a prescription for an oral antidiabetes drug or a noninsulin injectable drug. Using data from January 1, 2015, to June 30, 2016, Ms Wiechert and colleagues compared drug adherence, drug utilization, and overall plan costs in 1299 patients with diabetes whose copay was reduced versus 3845 patients whose copay remained the same. In the latter group with no reduction, the minimum copay was $10 for tier 1 drugs, $25 for tier 2 drugs, and $40 for tier 3 drugs.

Among patients whose copay was reduced to $10 per drug across all the tiers, tier 1 drug utilization remained stable, tier 2 drug utilization decreased, and tier 3 drug utilization increased; overall, the reduced copayments did not improve drug utilization significantly. Similarly, medication adherence did not differ significantly between the 2 groups, suggesting that a reduction in copay alone is not sufficient to improve adherence. Furthermore, the per-member per-month medication expenditure was $159 for patients whose copay was reduced versus $189 for those who continued to pay their typical copay.

“The value based benefit design (VBBD) consisting only of copayment reduction did not result in improved medication adherence in a large study size. Further efforts will be required to evaluate the effect of copayment reduction in combination with a disease statement management program to best assist PBM [pharmacy benefit manager] clients with choosing the most cost-effective VBBD plan,” concluded Ms Wiechert and colleagues.

[Source: Wiechert R, Deshponde M, Wuller C, Robinson C. Evaluation of a value-based insurance design program on medication adherence, utilization, and cost in diabetes.]

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Patient Education May Reduce Opioid Misuse and Diversion

Opioid abuse is expensive, totaling $14,000 per incident of opioid abuse for commercial health plans. Studies have shown that the primary source of misused opioids comes from family members and friends, and because disposal behaviors of unused opioids are not completely understood, designing optimal disposal and take-back programs has been difficult. A study by T. Christopher Bond, PhD, Purdue Pharma, Stamford, CT, and colleagues that was presented at the 2017 AMCP meeting demonstrated that patients who were educated about the risks of misusing opioids were more than 2-fold likely to properly dispose of their unused opioid drugs compared with patients who did not receive opioid disposal education.

A total of 152 patients with chronic noncancer pain who were prescribed opioid drugs from 2014 to 2016 were surveyed about their beliefs, motivations, and behaviors concerning the disposal of unused drugs. Overall, 59% of patients had acute and chronic pain, 31% of patients had chronic pain, and 10% of patients had acute pain.

Overall, 100 (65%) patients did not dispose of their unused opioid drugs, and had a median of 10 unused opioid pills. Of the patients who kept their unused opioid drugs, 84 patients did so for the future treatment of the same condition or a different condition, and only 3 patients reported keeping their unused opioids for friends or family.

Of the 33% of patients who disposed of their unused drugs, the majority did so within a month of stopping treatment, and approximately 50% used disposal kiosks or drug take-back programs. Overall, 84% of patients reported that they were likely or somewhat likely to prefer disposal kiosks and drug take-back programs as the means for disposing of their unused opioid drugs.

Furthermore, 39% of patients received provider-led education about disposing of unused opioids, and 13% of patients reported receiving reminders about disposing of unused opioids. Overall, 52% of patients who received provider education about opioids disposed of their unused opioids compared with 21% of patients who did not receive this education.

“When healthcare providers discuss risks of inappropriate use of medication, patients were 2.5 times more likely to properly dispose of their unused opioids,” suggest Dr Bond and colleagues.

[Source: Bond TC, Howard JC, Mayne T. Understanding factors that contribute to opioid misuse and diversion.]

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Capturing the Impact of Chronic Noncancer Pain Using Electronic Health Records

The consistent use of multidimensional assessment tools that measure the impact of chronic noncancer pain can help to improve patient outcomes and avert treatment failure and opioid abuse; furthermore, the use of technology can enhance data collection to achieve these improved outcomes. In a retrospective, cross-sectional study, Joel E. Mata, MD, Sharp Rees-Stealy Medical Group, and colleagues reported that utilizing a multidimensional chronic pain assessment tool (CPAT) embedded in an electronic health record system helped to track, capture, and report the severity of pain, patients’ functional status, anxiety, depression, and the risk for opioid abuse.

Between January and July 2016, a total of 216 patients with chronic noncancer pain who were receiving opioids or were considered for opioid therapy were administered the CPAT, which included a series of validated questions that assessed pain severity, function interference, pain duration, anxiety and depression, and the risk for opioid abuse. The CPAT was incorporated into the patients’ electronic health records as structured data fields.

Of the 198 patients who were included in the analysis, the average pain score, based on the CPAT, was 6.7, and the average function interference score was 6.1, on a 10-point scale. The average composite CPAT score was 18.8 points of a possible 58 points. Overall, 86% of patients had 3 or more comorbid chronic pain conditions; the 4 most common chronic pain conditions included lower back pain (81%), back pain (71%), joint pain (44%), and fibromyalgia (43%). In addition, the likelihood of depression, anxiety, and the risk for opioid abuse was low among this patient population.

A separate analysis compared the average number of monthly physician office visits, emergency department visits, and urgent care visits 12 months before patients were administered the CPAT and 6 months after patients received the CPAT. The results of this analysis showed that the CPAT decreased the per-patient monthly visits from 1.9 to 1.67 (P = .013), further demonstrating that systematic multidimensional assessment of chronic pain can improve the approach to treatment.

“This tool [CPAT] provides valuable information at the point of care that can assist with pain management strategies as well as provide broader chronic pain type and prevalence information,” Dr Mata and colleagues concluded.

[Source: Mata JE, Agnihotri P, Carda E, et al. Utilizing electronic health records to assess the severity and impact of chronic pain.]

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Payer Perspectives on the Use of Preemptive Pharmacogenetic Testing

Preemptive pharmacogenetic testing helps providers select optimal, individualized therapies for patients based on their germline genetic variants. The Clinical Pharmaco­genetics Implementation Consortium (CPIC) practice guidelines on translating genetic information into actionable prescribing decisions is a multiplexed, single genotyping assay that can help providers to make treatment decisions with confidence, especially when this assay is associated with little or no out-of-pocket cost to the patient. However, payer considerations for the financial reimbursement of preemptive pharmacogenetic screening are unclear.

A study presented by Nicholas J. Keeling, MS, University of Mississippi School of Pharmacy, and colleagues at the 2017 AMCP meeting sought to examine the knowledge level and perspectives of US payers regarding preemptive pharmacogenetic testing and to investigate the factors influencing the development of insurance coverage and reimbursement policies.

The investigators conducted in-depth phone interviews with 9 pharmacy directors and 5 medical directors, representing 28% of public insurance health plans (ie, Medicare and Medicaid) and 72% of commercial health plans, which together covered 122 million people. The average plan size comprised approximately 9 million members.

The survey results show that although payers are mainly unaware of the CPIC guidelines, they do believe that preemptive pharmacogenetic testing can be informative. However, some payers are concerned that this testing can lead to more expensive first-line treatments versus a one-size-fits-all treatment approach. In addition, many payers indicate that this testing currently lacked utility, because coverage decisions have not been established, and some payers would prefer real-world evidence over randomized controlled clinical trials for demonstrating the usefulness of preemptive pharmacogenetic testing.

The long-term benefits of this test will be difficult to appreciate, because many payers work on a 1-year budget cycle.

“Cost-benefit tradeoff determinations on one-year budget cycles may preclude the effective evaluation of pharmacogenetic test result utility,” stated Mr Keeling and colleagues. Overall, payer adoption of preemptive pharmacogenetic testing will require buy-in from several stakeholders, such as the US Preventive Services Task Force and the FDA. Other factors influencing payer acceptance of pharmacogenetic testing include increased evidence demonstrating the benefit of this test in reducing hospitalization rates and improving health outcomes.

“Evidence from real-world implementation projects, prospective outcome studies, population health metrics, and robust budget impact models to predict downstream economic benefits are important areas for future research in preemptive pharmacogenetics,” concluded Mr Keeling and colleagues.

[Source: Keeling NJ, Rosenthal M, West-Strum D, et al. Preemptive pharmacogenetic testing: exploring the knowledge and perspectives of United States payers.]

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Last modified: May 9, 2017
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