Engaging the prescriber and the PCP in controlling pharmacy costs

May 5th, 2017 / By Steve Delaronde

Sovaldi is a prescription drug that was approved by the FDA in December 2013 to treat Hepatitis C. The following year, the total cost of prescription drugs in the United States rose by an unprecedented 14.2 percent. Since then, there has been no shortage of news stories pertaining to the high cost of drugs. Payers scramble to find ways to control spending, but since drug manufacturers can set their own prices, there is little room for negotiation. Traditional consumer-oriented approaches to pharmacy cost control such as tiering, pre-authorization, value-based insurance design, and step therapy help a little, but additional strategies are needed. These approaches need to be supplemented with provider-level solutions, since there is no prescription drug use without a prescriber.

Once it is determined that medication is truly indicated to treat a patient’s condition, the prescriber often has multiple options. Generic drugs are nearly always less expensive than brand drugs, and over-the-counter (OTC) drugs are available in some cases. Proton pump inhibitors (PPI) for the treatment of GERD (gastroesophageal reflux disease) represent a good example.  Omeprazole (Prilosec) and Esomeprazole (Nexium) can be used interchangeably for most patients with some limited exceptions. The price for a single 20 mg capsule of generic omeprazole is about $1 and about $7 for generic esomeprazole, while branded Nexium can be as high as $15 per capsule. Over-the-counter Prilosec and Nexium cost about $0.50 per 20 mg capsule. Even with OTC options, generic and brand name PPIs are still widely prescribed.

The second approach to controlling overall medical costs with pharmaceutical drugs is through improved adherence, particularly for drugs used to treat chronic conditions. An article appearing in The New York Times in April 2017 concludes:

“There is an out-of-control epidemic in the United States that costs more and affects more people than any disease Americans currently worry about. It’s called nonadherence to prescribed medications, and it is—potentially, at least—100 percent preventable by the very individuals it afflicts.” 

Medication adherence rates are typically around 50 percent with non-adherence associated with potentially preventable ER visits, hospitalizations and higher medical costs. The responsibility of the prescriber does not end with the prescription pad, but requires patient follow-up to assure that they are taking medications as prescribed. This follow-up can be provided by the prescriber, PCP, nurse, care manager or a pharmacist. A standardized approach to optimizing medication indication, dosage, safety and adherence is available through medication therapy management (MTM). The first step to improving adherence, however, is awareness of the problem and the proper identification of patients who are non-adherent.

A third approach to controlling pharmacy costs is recognizing and addressing the variation that occurs among physicians and physician practices in costs, quality and outcomes related to chronic conditions. A risk-adjusted comparison of patient panels with potentially high cost conditions, such as diabetes and heart disease, is necessary to understand where variation can be identified and managed. One study identified an 18-fold difference in diabetes medication prescribing practices across 139 facilities even after controlling for certain patient characteristics.  Identifying the top performing providers in quality, cost, and outcomes can serve as a benchmark and example to underperforming practices.

Ultimately, there are multiple methods available for controlling pharmacy costs. Incentives that leverage pay for performance, patient-centered medical home, and accountable care arrangements between payers and providers offer an opportunity to engage the prescriber and PCP (when they are not the same person). Increasing awareness of lower cost, but equally effective, medication options is a good start. Keeping providers involved with patients after the prescription is written, as well as keeping them informed of how their prescribing and practice patterns differ from their peers, represent additional opportunities to achieve the Triple Aim of better care, lower costs, and a better patient experience.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.