The following summaries highlight some of the key posters presented at the 26th Annual Meeting of the Academy of Managed Care Pharmacy (AMCP), April 1-4, 2014, in Tampa, FL, focusing on areas of interest for payers, employers, drug manufacturers, providers, and other healthcare stakeholders.
Pharmacist-Provider Collaborative Care Model Improves Diabetes Outcomes
A pharmacist-run medication therapy management (MTM) program in association with the provider can improve outcomes for patients with high-risk diabetes, according to a study by Nicole Hancy, PharmD, Director of Clinical Services, WellDyneRx, and colleagues. The investigators set out to evaluate the impact of a collaborative MTM program between a large managed Medicaid group and WellDyneRx, a full-service prescription benefit manager in Englewood, CO.
WellDyneRx provides services to health plan members through a retail network of more than 65,000 pharmacies nationwide. The use of a targeted letter-writing campaign to physicians led to improved medication adherence in approximately 50% of the patients with diabetes who were identified as nonadherent to their diabetes medications.
“Pharmacists involved in a team-based care model can have positive contributions to patient care and safe medication use,” said Dr Hancy. “Our program promoted partnerships between the pharmacist and healthcare provider to enhance communication, improve collaboration among all parties involved, and, ultimately, optimize diabetes therapeutic outcomes.”
The study population included 244 patients with diabetes, defined as hemoglobin (Hb)A1c ≥9%, who were involved in an MTM program. In this program, a clinical pharmacist was linked to a primary care physician to perform a comprehensive medication review of patients with diabetes every 3 to 4 months. Pharmacists identified patients who were not adherent to their medication, had gaps in care, and/or lacked appropriate follow-up for HbA1c testing.
Nonadherence was measured by medication possession ratio (MPR); gaps in care, defined as a necessary change in therapy; and lacking statin, angiotensin-converting enzyme (ACE) inhibitor, or angiotensin receptor blocker therapy. Physicians with nonadherent patients received intervention letters from their respective pharmacist identifying medication nonadherence in the patient.
Three months after the intervention letters were sent to the providers of 101 patients with diabetes, the noncompliant patients had an average reduction in HbA1c of 0.8 mg/dL. In another cohort of 74 noncompliant patients, HbA1c was reduced by an average of 1.1 mg/dL 3 months after letters were sent out.
In the cohort of 101 targeted patients, 42 had a reduction in HbA1c, with the average reduction of 1.7 mg/dL. In the cohort of 74 targeted patients, 23 had a reduction in HbA1c, with an average reduction of 2.2 mg/dL. A total of 86 recommendations were made to address medication adherence in the 101-patient cohort, with 57% seeing an improvement in adherence, with an MPR of ≥80%. In the 74-patient cohort, 51 recommendations were made, and 43% of patients had an improvement in medication adherence, with an MPR of ≥80%. Approximately 56% of patients had their HbA1c rechecked when they were alerted to do so by the letters.
Approximately 15% of patients in the 2 cohorts identified as having gaps in care in their drug history were started on corresponding therapy such as ACE inhibitors or statins. However, because clinical information (ie, serum creatinine and comorbid conditions) were not available to the pharmacists, it is unclear whether this low percentage was caused by patients not actually being candidates for the recommendations. The study is ongoing, and the researchers plan to send out provider feedback forms with future intervention letters so that response to the recommendations can be better assessed.
[Poster: Hancy NE, Henderson MA, Taddei-Allen P, Page RN. Impact on pharmacist run medication therapy management program on diabetic patients.]
Copay Waiver Incentive Used to Increase Mail-Order Medicines and Medication Adherence
Copay incentives can be used to encourage the use of mail order for prescription refills, spurring an increase in medication adherence is the conclusion from a study led by Nirmal K. Ghuman, PharmD, MPH, Senior Consultant, Analytic Consulting Services, CVS Caremark.
Previous studies have demonstrated that patients who receive prescription refills through the mail have better medication adherence compared with individuals who refill their medications at local pharmacies. For example, in a 2010 study involving 13,922 patients with diabetes, those who received their medications by mail were more likely to take the drugs as prescribed than those who received their drugs from a pharmacy—84.7% versus 76.9%, respectively (P <.001).1 As a result, healthcare groups have been testing various approaches to incentivize individuals to use mail order for their medications.
In 2008, a large group health plan implemented a unique incentive that allowed households of members using mail-order service in the last 4 months of the plan year to be eligible for a $50 waiver. The waiver could be used for household copays at local pharmacies during the next plan year. Individuals could qualify for the incentive annually if they continued to use mail order for their medications.
In the new study, Dr Ghuman and colleagues evaluated the impact of the retail copay waiver on long-term medication adherence and mail-dispensing rate. The team reviewed the annual average medication possession ratio (MPR) from 2007 to 2012 for medications used for several chronic conditions, including hypertension, hyperlipidemia, diabetes, asthma/chronic obstructive pulmonary disease (COPD), and heart failure.
The plan had an average of 30,000 members throughout the study period. The average member age was 80.2 years, and approximately 30% were male. On average, 14.9% of the plan’s population participated in the retail waiver program from 2008 to 2012.
The researchers found that the mail-dispensing rate increased over the study period, and the medication adherence improved for each of the 5 chronic conditions examined. Compared with 2007, the MPR in 2012 was increased by approximately 1% for medications for hypertension, hyperlipidemia, heart failure, and diabetes. For asthma/COPD medications, the MPR rose from approximately 59% in 2007 to almost 64% in 2012.
The researchers concluded that other clients may want to consider providing similar retail copay waivers to promote mail utilization and to improve medication adherence. Future research will attempt to determine whether there are certain member characteristics or demographics that make patients more likely to participate in the retail copay waiver program.
- Duru OK, Schmittdiel JA, Dyer WT, et al. Mail-order pharmacy use and adherence to diabetes-related medications. Am J Manag Care. 2010;16:33-40.
[Poster: Ghuman NK, Shuey R, McGowan J. Impact on long-term adherence and mail dispensing rate of incentivizing utilization of mail through participation in a retail waiver program.]
Coverage Decisions for Genetic Testing and Personalized Medicine
Genetic testing and personalized medicine are seen as the waves of the future for many diseases, especially for cancer. Little is known about the current coverage, payers’ attitudes about future expansion of coverage, and the determinants of that coverage.
According to a recent online survey, the majority of payers currently cover at least some genetic testing and personalized medicine, and plan to evaluate the need for expanded coverage of these services, according to the survey.
One of the most important findings from this study is that payers are seeking more pharmacoeconomic data that show the value of genetic testing as it relates to the selection of therapy and patient outcomes to make coverage decisions.
“Many of the new medications are specialty pharmaceuticals, and many have genetic tests to go along with them. We wanted to see if payers are onboard with advances in pharmacogenomics. The majority of payers are interested in expanding coverage for these services, but need more pharmacoeconomic data to demonstrate cost-effectiveness,” said lead investigator Nisreen Shamseddine, MS, of Xcenda, Palm Harbor, FL.
“Of the 100s of genetic tests listed in the National Comprehensive Cancer Network Biomarker Compendium, decision makers do not know which ones have value. The take-home message of our study is that, overall, genetic testing is important to decision makers, but they are currently operating without full information,” noted coinvestigator Melissa S. Denno, PharmD, MS, Manager, Global Health Economics and Outcomes Research, Xcenda.
The study was based on a double-blind online survey conducted between July 18, 2013, and August 4, 2013. The survey consisted of 28 questions about current and future coverage decisions regarding genetic testing and personalized medicine, including health economic questions.
The 60 respondents included pharmacy and medical directors representing coverage of 107 million lives. Regional plans (60%) and national plans (38%; 2% unspecified) representing commercial, Medicare, and/or Medicaid plans were included. The types of plans included managed care organizations, integrated health delivery systems, preferred provider organizations, and pharmacy benefit managers.
Of the respondents, 90% said that they currently covered some form of genetic testing, with approximately 40% of plans covering between 76% and 100% of the cost. Slightly more than 83% of the respondents noted that requests for genetic testing from physicians and patients have increased over the past 5 years. In all, 68% of respondents plan to increase coverage for genetic testing over the next 5 years compared with 5% who want to decrease coverage, approximately 17% who want to maintain the same coverage, and 10% who are unsure.
Responding to the question of in which diseases is genetic testing expected to have significant impact on clinical outcomes, 98.3% of respondents identified cancer, 41.7% also identified cystic fibrosis, 26.7% noted HIV/AIDS, 25% indicated cardiovascular disease, and 16.7% added Alzheimer’s disease.
When asked which available biomarkers were currently covered by plans, the 2 most frequently covered were HER2 for breast cancer (95% of plans) and KRAS mutation testing for metastatic colorectal cancer (91.7%).
Respondents said that literature was scarce about the cost-effectiveness of genetic testing and personalized medicine; 45.7% believe that personalized medicine would increase the cost of care for their plans.
A large majority (83.4%) of plans believe that genetic testing would dictate decisions about treatment selection. When asked what factors were clinically important for personalized medicine, the 3 most frequently named factors were predicting response to an agent, getting the most effective therapy the first time, and more efficient management of cost.
Respondents were fairly evenly split regarding the requirement for US Food and Drug Administration (FDA) support of genetic tests; 35% would require FDA regulation to cover a pharmacogenomic test, 30% would require at least an FDA recommendation, and 35% said that they would not need the FDA to weigh in on the issue if the scientific evidence were sufficient in support of such testing.
Overall, 38.3% of respondents expressed interest in partnering with pharmaceutical companies in ways such as risk-based contracting or biomarker awareness programs to understand the value of genetic testing in the future.
[Source: Shamseddine N, Denno M, Jackson J. Payers’ perspective on the future of genetic testing and personalized medicine.]
Intravenous Cancer Treatment Pricier in Hospital Outpatient than in Office-Based Setting
A new study has demonstrated that intravenous (IV) cancer therapies are more costly, by approximately 10%, when patients receive them in a hospital outpatient setting rather than in a community-based physician office. The study was presented at the 2014 Academy of Managed Care Pharmacy annual meeting.
Coinvestigator Barbara L. McAneny, MD, Chief Executive Officer and Managing Partner, New Mexico Cancer Center, Albuquerque, said that this research adds to the growing evidence that care is more costly in the hospital setting. “As we switch to more high-deductible health plans, out-of-pocket costs per patient go up considerably, which makes cancer care increasingly difficult for patients to afford,” Dr McAneny said. “The current trend of acquisition of practices by hospitals is exactly the wrong direction for the country to be going in at a time when healthcare costs are spiraling out of control.”
This new retrospective analysis was based on pharmacy and medical claims compiled from the HealthCore Integrated Research Database, a database containing information from approximately 32 million members of 14 commercial health plans in the United States. The researchers gathered data from adults aged 18 to 65 years who received IV cancer treatment with a chemotherapy or a biologic agent between January 1, 2006, and August 31, 2012. Patients were included if they had 2 or more medical claims at least 30 days apart for a cancer, no secondary cancer, and at least 6 months of preindex and postindex health plan eligibility.
Patients were assigned to a community physician office cohort or a hospital outpatient cohort, depending on where they received at least 95% of their IV treatment. The researchers focused on 5 different cancer types in 18,740 patients: early breast cancer (47.5%), metastatic breast cancer (22.1%), non-Hodgkin lymphoma/chronic lymphocytic leukemia (11.9%), metastatic lung cancer (10.1%), and colorectal cancer (8.4%).
During a 12-month period, the average total healthcare costs were significantly higher for patients who received treatment in the outpatient setting than in the community setting—$122,473 versus $82,773 (P <.001).
Patients seen in the outpatient setting also had longer treatment durations—415 days versus 300 days, respectively (P <.001); higher 6-month treatment costs—$103,460 versus $68,792, respectively (P <.001); and higher 12-month treatment costs—$143,206 versus $98,071, respectively (P <.001).
The difference was more acute in the “other outpatient services” category, and the researchers speculate that this could be caused by high reimbursement for facility fees and services in the hospital outpatient setting. After adjusting for baseline characteristics, the average annual costs for patients seen in community offices were 8% lower than for patients seen in a hospital outpatient setting.
[Poster: Fisher MD, Yim YM, Luthra R, et al. Effect of treatment setting on healthcare costs in five major cancer types from a large commercially insured population.]
Costs Increase in Last 6 Months of Life for Patients with Metastatic Breast Cancer
Patients with HER2-positive metastatic breast cancer consume 2.5 times more financial resources when they are within 6 months of death, according to a retrospective, observational review based on data from the IMS LifeLink Health Plan Claims Database between January 1, 2002, and June 30, 2012.
The study highlights real-world healthcare resource utilization and costs of patients with HER2-positive metastatic breast cancer who received trastuzumab near the end of life. Patients were excluded if they received lapatinib for first- or second-line therapy. IMS LifeLink is a comprehensive database of integrated medical and pharmacy claims from more than 79 US health plans, for approximately 87 million deidentified lives. The researchers divided the patients into 2 cohorts: 670 patients who were alive at the end of the 6 months of follow-up, and 196 patients who were dead by the end of the 6-month follow-up period.
The investigators calculated costs from the allowed amount on the claims, which were adjusted for inflation to 2012 US dollars. The mean 6-month total healthcare cost was almost 3 times higher in patients who died during the predefined period than in patients who were still alive—$69,426 versus $26,857 (95% confidence interval, 3.133; P <.001).
The mean costs were significantly higher for each healthcare component cost measured for those who were dead at the end of the 6-month period and those who were alive:
- Inpatient hospital care: $18,883 vs $2706
- Hospice: $2214 vs $2
- Emergency department: $1667 vs $212
- Physician office: $22,816 vs $10,579
- Other outpatient: $18,569 vs $11,056
- Home health/durable medical equipment: $670 vs $210
- Pharmacy: $4659 vs $2092.
In the cohort of patients who died, there was a 20-fold increase in inpatient costs and a 14-fold increase in hospice costs between the sixth month and the first month before the end of life. Emergency department cost and home healthcare cost also increased in the last 2 months of life. “The main driver of higher costs during those 2 last months is hospitalization,” said the lead investigator of the study, Thomas J. Bramley, RPh, PhD, Senior Vice President, Scientific Consulting, Xcenda.
In the cohort of patients who were still alive at 6 months, the monthly costs were similar throughout the study. The researchers cautioned that results cannot be generalized to patients who were not commercially insured or who had HER2-negative breast cancer.
Amy P. Abernethy, MD, PhD, Palliative Medical Specialist, Director, Duke Cancer Care Research Program, said that the finding that healthcare, especially inpatient care and hospice costs, is more expensive in the last 6 months of life is consistent with other studies. As people get sicker, they need more healthcare, including treatments for cancer and hospitalizations, suggests Dr Abernethy.
Hospice care, which helps keep people out of hospitals, increased in the last 6 months, potentially lowering some of the inpatient costs. The researchers did not provide information on whether the treatments that were provided made “good sense.”
“Part of the problem is that it is really hard to figure out who is going to die and who needs a shift to a hospice focus and when. We can’t say whether or not there is any signal [in this study] that these women should not have been getting therapy, because we don’t actually have a sense of how sick they were at the time of treatment,” Dr Abernethy pointed out. “The number one take-home message is that we have to get better at figuring out where people are on the curve of prognosis, so that we can help them make good decisions.”
[Poster: Bramley T, Cheng Q, Lunacsek O. The economic burden of end-of-life care in metastatic breast cancer.]