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Payers’ Perspectives: Health Economics Outcomes in Managed Care

May 2015, Vol 8, No 3 - Conference Highlights AMCP
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  The following summaries represent a sample of the many studies presented at the 27th Annual Meeting of the Academy of Managed Care Pharmacy (AMCP), April 7-10, 2015, in San Diego, CA. These summaries highlight some of the main trends in the current US healthcare, reflecting the impact of real-world, evidence-based issues of high interest for payers, employers, drug manufacturers, providers, patients, and other healthcare stakeholders.  

Medication Adherence in Public Exchanges Not Different from Commercial, Nonexchange Plans

There has been considerable debate about the quality of the care provided in the public health insurance exchange plans. A new analysis compared medication adherence between public health insurance exchange plans and commercial nonexchange plans using real-­world medication possession ratio (MPR) data, demonstrating a lack of significant difference between patients in public health insurance exchange programs and those covered by commercial nonexchange plans in terms of drug therapy for chronic disease.

The results of this retrospective, case-controlled study by Kheelan Gopal, PharmD, of CVS/Caremark, and colleagues, were presented at the 2015 AMCP meeting. Medication adherence was assessed by MPR, showing no significant difference in patient adherence across 4 common chronic conditions.

In the brief history of the public health insurance exchange plans, little information has emerged regarding the metrics associated with utilization and cost of care. Dr Gopal and colleagues sought to inform the issues by comparing medication adherence rates, cost, and utilization in public plans versus in commercial insurance plans.

The results showed that medication utilization was similar across plans, even though the public exchange population was older, they added. However, patients who were enrolled in the public exchanges did lag behind in terms of optimal adherence to therapy. Nevertheless, “although there was a statistical difference in optimally adherent members between the public exchange population versus the comparators, this finding is not clinically significant due to a number of factors,” the investigators emphasized.

The public insurance exchanges included generic drugs more often than commercial insurance plans, and the annual per-member cost of medication was generally lower across various medication categories compared with members in employer or other commercial health insurance plans.

The investigators examined claims for public exchanges (not including Medicare or Medicaid) and for commercial nonexchange plans for the period between January 1, 2014, and December 31, 2014. They limited their review to medications for the treatment of the 4 chronic conditions—hyperlipidemia, depression, diabetes, and hypertension. The analysis compared the results of public exchanges, employer-provided plans, and nonemployer commercial plans.

The public exchanges had a generic dispensing rate of 87.42% versus 81.37% in employer-provided plans, respectively, and 82.95% in the other health plans. The mail dispensing rate was higher in the employer-provided plans (49.04%) than in the health plan (10.49%) or public insurance exchanges plan (9.65%) populations.

The age-adjusted MPR did not differ among the 3 types of plans for any of the 4 conditions, including ­hyperlipidemia (range, 74%-80%), depression (range, 69%-73%), diabetes (range, 73%-79%), and hypertension (range, 75%-82%).

The rates of optimal therapy were lower in the public insurance exchanges plan than in the other populations for all 4 conditions, including hyperlipidemia (55% vs 61%-66%, respectively; P <.01), depression (49% vs 50%-55%, respectively; P <.01), diabetes (52% vs 56%-61%, respectively; P <.01), and hypertension (58% vs 64%-70%, respectively; P <.01).

Antiviral drugs were the top drug class by utilization for the public exchanges, at a cost of $147.72, surpassing employer ($74.28) and nonemployer ($87.12) commercial plans. For the remaining top 10 drug classes, the public exchanges had lower or similar costs compared with the commercial plans (antidiabetes drugs, analgesics/anti-inflammatory drugs, psychotherapeutic/neurologic drugs, antiasthmatic/bronchodilator drugs, dermatologics, opioids, antineoplastics/adjunctive therapies, antidepressants, and antihyperlipidemic drugs).

“The public insurance exchange plans are similar to the health plan population in terms of utilization; however, the public insurance exchange has an overall older population and higher generic utilization than observed in the commercial non-exchange population,” Dr Gopal and colleagues observed.

[Source: Gopal K, Nguyen J, Chalker JL, Weber B. Analysis of adherence between public health insurance exchange plans and commercial non-exchange plans.]

Medicaid Expansion Beneficiaries More Adherent to Hepatitis C Therapy than Traditional Medicaid Population

Under the Affordable Care Act (ACA) expansion plan, more members with hepatitis C virus (HCV) infection now qualify for Medicaid, thereby increasing the risk for Medicaid plans, because of the high cost associated with the new HCV therapies.

A group of pharmacists from Passport Health Plan, a managed Medicaid plan with more than 200,000 members in Louisville, KY, conducted a retrospective analysis to compare utilization trends of HCV therapies between expansion patients and traditional Medicaid patients in their plans. They presented their results at the 2015 AMCP meeting.

Using pharmacy claims from their Medicaid plan, Mary Bystrek, PharmD, and colleagues found that new members who were eligible for Medicaid under the ACA’s expansion program had a substantially lower discontinuation rate with sofosbuvir regimens than the traditional Medicaid population that was treated for HCV.

Dr Bystrek and colleagues compared the utilization and discontinuation of sofosbuvir-containing regimens among a Passport Health Plan expansion Medicaid population and a traditional Medicaid population, which included all other categories of aid. Their retrospective analysis included pharmacy claims for members who started sofosbuvir therapy between January 1, 2014, and August 1, 2014.

The data analysis included 143 members, 40% of whom were from the expansion cohort. Overall, members with Medicaid expansion account for 35% of Passport Health Plan’s total membership.

The analysis showed that 111 (77.6%) of the 143 members completed their treatment. The 143 patients included 129 patients who received sofosbuvir plus ribavirin, with or without pegylated interferon, which was associated with a discontinuation rate of 22.6%.

Among the 75 (52%) patients who received an interferon-free regimen, the discontinuation rate was 22.4%. Medicaid members who received simeprevir-containing regimens had a discontinuation rate of 17%.

Overall, 32 patients discontinued treatment before the completion of their regimen, consisting of 22 patients from the traditional Medicaid cohort and 10 patients from the expansion cohort. A total of 22.4% of patients discontinued their HCV treatment before completion of the regimen. However, the discontinuation rate was 26% for the traditional population versus 18% for the expansion cohort that qualified for Medicaid coverage through the ACA.

Moreover, the traditional Medicaid cohort accounted for 69% of all discontinuations that occurred during the 12 months of follow-up.

“Forty percent of sofosbuvir utilizers were expansion members, correlating with the top drug spend among this population,” observed Dr Bystrek and colleagues. “The expansion population had a lower discontinuation rate than the traditional population. As many expansion members were new to receiving a healthcare benefit, perhaps this population was more committed ­to therapy.”

Throughout 2014, sofosbuvir topped all other drugs in terms of expenditures for Passport Health Plan. In this Medicaid plan, sofosbuvir ranked at the top across all categories of aid. Few studies have examined the rates of discontinuation and adherence to sofosbuvir regimens among patients who qualified for Medicaid coverage through the ACA.

“As revised criteria have recently been set for all hepatitis C medications at Passport Health Plan, it will expectantly become easier to follow members on therapy and evaluate discontinuation rates while also considering clinical information,” the investigators concluded. “It will be of value to continuing monitoring those on therapy as new medications are released and as Passport Health Plan’s membership continues to grow.”

[Source: Bystrek M, Armstrong C, Wathen C. Analysis of Sovaldi (sofosbuvir) utilization in a KY Medicaid traditional and expansion population.]

Increasing Interest of Payers in Partnering with Manufacturers on Programs for Drug Adherence in Specific Disease States

Payers express a cautious but growing interest in partnering with drug manufacturers to improve patient medication adherence, according to a recent study based on payer surveys presented at the 2015 AMCP meeting.

Payers’ willingness to participate in adherence programs that target high-risk patient populations increased from 37% in 2011 to 43% in 2014, but that increase in 2014 actually represented a more than 10% decline from 2013, when 48% of survey respondents to the 2013 survey indicated a willingness to partner with manufacturers to improve patient medication adherence. This up-and-down trend may reflect some payer ambivalence toward partnerships with drug manufacturers specifically about medication adherence.

“Payers are interested in participating in compliance/persistency programs despite significant barriers, such as financial and operational problems,” suggested Lindsay Allen of Mercer University, Macon, GA, and an intern at Xcenda, Palm Harbor, FL, and colleagues from Xcenda.

The study included responses to 3 surveys of payers representing 100 million to 150 million covered lives annually. A total of 59 payer respondents completed the survey in 2011, 60 responded in 2013, and 56 in 2014. A majority of the payer respondents represented managed care organizations.

The responses to the 2014 survey showed that the total cost-savings was the principal reason for participating in partnership adherence programs for 55% of payers.

Regarding barriers to participating in drug adherence programs, survey respondents cited lack of integration (57%) and cost (48%) as the greatest barriers to their participation in such programs. Other key influencing factors were a lack of necessary technology (41.1%), lack of efficacy data (39.3%), no supporting payment or business strategies in place (26.8%), and a lack of incentives in the Affordable Care Act or by Medicare (23.2%).

The cumulative data from the 3 surveys revealed various factors driving payer interest in drug adherence programs across the different disease categories:

  • For arthritis, the biggest driver was increased patient satisfaction (43%)
  • Quality improvement headed the list of factors for cholesterol management (75%)
  • The total healthcare costs fueled interest in adherence for cardiology and/or diabetes (86%) and for multiple sclerosis (57%).

Payers’ interest in sharing claims data for high-risk populations with manufacturer partners remained fairly stable at 27% in 2011, 33% in 2013, and 27% in 2014. Across the 3 surveys, 83% to 93% of payer respondents said that the effect of adherence or persistence programs on hospitalization was the most impactful data.

In addition, at least 80% of respondents annually said that reductions in overall costs related to disease state and emergency department visits constituted impactful data.

“While payers are interested in partnership opportunities with manufacturers, data sharing is a significant area of concern. Partnerships between payers and manufacturers within certain disease states will be most productive when they align with payer needs (eg, improvement of quality measures, decrease of total costs),” Ms Allen and colleagues observed.

[Source: Allen L, Jackson J, Denno M. Trends in medication adherence: a payer’s perspective.]

Mixed Results with Prior Authorization for Drug Compounding Pharmacies

More than 7500 pharmacies are specializing in compounding services in the United States, and they process more than 30 million prescriptions annually. To reduce the costs associated with compounding and ensure appropriate utilization, many health insurance plans have instituted prior authorization for claims that exceed specific thresholds.

A new analysis conducted by CVS/Caremark showed that prior authorization policies have mixed results with respect to controlling the costs associated with multi-ingredient compound medications. The results of this retrospective analysis of claims data from CVS/Caremark were presented at the 2015 AMCP meeting by Ahmed M. Guhad, PharmD, CVS/Caremark, and colleagues.

Placing a $400 cost limit per compound per claim submitted to the pharmacy led to a reduction in the average cost per compound claim, as well as the total plan costs for compound claims. However, the volume of claims for compounds costing from $251 to $400 increased by 86%, potentially reflecting split filling of prescriptions by the compounding pharmacies.

Claim costs for compounded pharmaceuticals have increased dramatically in recent years. For example, the number of compound claims increased by 100% over the past 3 years within the CVS/Caremark employer book of business, and the gross cost per compound claim increased by 1700%, the researchers noted.

To deal with the rising number of and costs associated with compound claims, some payers have implemented prior authorization policies. The impact of the policies on claims and costs has not been studied extensively.

Dr Guhad and colleagues analyzed compound claims data for multiple plans from March 2014 to October 2014. They compared cost and utilization metrics for 717 plans that opted in to a prior authorization program with a $400 limit per compound claim with the cost and utilization of 39 plans that opted out.

The data showed that plans that opted out of prior authorization had an average cost per compound claim that was almost 8 times higher than that of the plans that opted in (P <.05). Opt-out plans had a 14% increase in the total cost of compound claims, whereas opt-in plans had a 90% decrease. In the opt-in group, 0.5% of the compound claims exceeded a cost of $400.

The total number of compound claims increased by 3% in the opt-out plans, whereas the number of compound claims decreased by 19% among the opt-in plans, despite an 86% increase in the number of claims that cost $251 to $400.

In the opt-out group, 5 ingredients accounted for 56.7% of the total cost of all compound claims—flurbiprofen powder, gabapentin powder, fluticasone powder, ketamine hydrochloride powder, and resveratrol powder. Five ingredients accounted for 43.2% of the total cost of compound claims in the opt-in group—flurbiprofen, gabapentin, ketamine hydrochloride, progesterone powder for micronization, and PracaSil-Plus.

“The specialties of nearly one third of the prescribers of multi-ingredient compound prescriptions are unknown,” Dr Guhad and colleagues observed.

“Prior authorization with a dollar limit can help decrease plan cost and utilization of compound claims,” they noted. “If the cost and utilization of compound claims continue to grow, additional strategies may be warranted.”

[Source: Guhad AM, Brinson J, Jay MA. Utilization and cost metric analysis on the impact of a PA program targeting compound claims.]

Managed Care versus Fee-for-Service Care: Modest Cost Advantage, No Quality-of-Life Difference

Managed care plans have achieved mixed results in their quest to control medical costs while maintaining patient satisfaction. In a national survey of medical expenditures comparing managed care versus fee-for-service (FFS) care, managed care had a slight cost advantage over FFS care, but the 2 strategies came out even in terms of health-related quality-of-life (HRQOL) scores, according to Aniket A. Kawatkar, PhD, MS, BPharm, of Kaiser Permanente Southern California, Pasadena, who presented the results at the 2015 AMCP meeting.

The total out-of-pocket (OOP) costs for managed care members averaged $147 less than the OOP costs for patients receiving FFS care. Inpatient care and medication costs accounted for most of the difference. The 2 cohorts had similar scores for composite physical and mental health, as ascertained by the Short Form-12 version 2 (SF-12) HRQOL instrument.

Data for the analysis came from the 2012 Medical Expenditure Panel Survey Household Component, a nationally representative survey of the noninstitutionalized US civilians. Data were extrapolated nationwide, resulting in 2 patient populations exceeding 50 million persons each. The primary outcomes were OOP costs and expenditures (consisting of overall total, office visits, office physician visits, hospital outpatient visits, emergency department visits, inpatient stays, and prescription drugs) and the 2 composite scores of the SF-12.

The study population included a mean age of approximately 48 years, 81% were white, 53% were women, 92% were residents in a metropolitan statistical area, and 51% were categorized as having a high income. The managed care and FFS groups did not differ substantially with respect to health status or specific diseases or conditions.

After adjustment, the overall total expenditures were $241 less in the managed care group, and the total OOP costs were $147 less. Of the $147 differential, the inpatient costs accounted for $65, prescriptions for $55, office visits for $14, hospital outpatient visits for $10, and emergency department visits for $6.

“Economic efficiency of participation in managed care plans was limited to small out-of-pocket cost savings in this nationally representative US sample,” reported Dr Kawatkar. “Further research is necessary to understand the trade-off between choice restrictions of managed care participation and lower out-of-pocket patient costs.”

Key drivers of the total expenditures were inpatient expenditures ($190 less with managed care), hospital outpatient care ($63 less), and prescriptions ($56 less). Office visits and office physicians visits were $122 and $109 higher, respectively, with managed care than with FFS care. The HRQOL scores of the 2 patient populations were virtually even for the physical and mental composites of the SF-12.

[Source: Kawatkar AA. Out of pocket cost, expenditures and health related quality of life in managed care plan members.]

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Last modified: August 30, 2021