PHARMACY

Medication therapy management contribution to improved outcomes and cost savings in health care

BY Nathan Ludvigson

By now we are all well aware of the healthcare IT transformation taking place across the nation. This transformation is expected to continue for the foreseeable future with further implementation of Meaningful Use and the expansion of state Medicaid programs in 2014 as a result of the Patient Protection and Affordable Care Act requirements. Providing clinical services through the coordination of care among a variety of providers in the healthcare space will continue to be a focal point in the future of healthcare as well. For example, we will likely see more elaborate collaborative care models through the expansion of accountable care organizations, patient centered medical home efforts, and the development of health insurance exchanges in one form or another.

As HIT continues its evolution down this path, the center of attention is expected to shift from provider and hospital adoption of HIT, data exchange and interoperability towards a rigorous focus upon improving patient outcomes and cost savings throughout the system. Improved patient outcomes and cost savings are the end goals of HIT transformation, with clinical exchange and interoperability being the means towards those ends. Furthermore, “adherence” will continue to be a buzz word in healthcare, and a means of achieving the goals of improved outcomes and cost savings.

And this is where medication therapy management helps fill the void. As we know, medication non-adherence continues to be a burden on the healthcare system. According to the New England Healthcare Institute, the annual costs nationally as a result of medication non-adherence are in the neighborhood of $290 billion. In November, the Congressional Budget Office issued a statement summarizing the results of a review of recent research estimating that greater prescription drug use by Medicare beneficiaries contributes to a reduction in Medicare’s spending for medical services. This study may be a springboard to help move comprehensive MTM legislation through Congress in 2013-2014. In recent years, comprehensive MTM legislation and thus greater adoption in the marketplace of MTM, has been slowed by other more pressing, omnibus healthcare efforts: namely ACA and HITECH.

It’s worth mentioning that industry leaders, NCPA and NACDS recently sent a letter to the Centers for Medicare and Medicaid Innovation asking it to clarify that pharmacists are providers for the purposes of participating in new delivery system models such as ACOs and PCMH. With expanded definitions of pharmacists as healthcare providers, clarity can be established around reimbursement for clinical services offered in the Pharmacy. Further, CMS just released an MTM report focused on the chronically ill. The report analyzes reduced prescription drug costs and hospitalization costs among patients with chronic illness like congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) who were newly enrolled in a Medicare Part D MTM program in 2010. The CMS study found that in comparison to Medicare beneficiaries with CHF or COPD who did not receive any MTM services in 2010, those who were enrolled in MTM programs experienced significant improvements.

Now that outcomes and cost savings are garnering more of the attention in both policy circles and the marketplace, the pharmacy has a golden opportunity to continue its push for becoming a major participant in the effort of tackling these dual objectives. Whether MTM is administered in the retail setting or within the context of an ACO, PCMH or hospital/clinic setting, the pharmacy has a critical role to play in the future of healthcare.

Nathan Ludvigson and Tom Bizzaro will be presenting an educational session at the national NCPDP conference titled, “The Collaborative Pharmacists,” which will include a policy overview of MTM on May 8, 2013.


As Director of Business Development with Pharmacy Services for Emdeon, Nathan Ludvigson directs policy and business development for Pharmacy Services related to electronic prescribing, Health Information Exchange (HIE), Medication Therapy Management (MTM), Prescription Monitoring Programs (PMP), Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), and other pharmacy services areas. Nathan also identifies, analyzes and makes recommendations regarding key legislative issues and regulatory matters impacting the pharmacy industry as needed with the pharmacy services executive team. Nathan combines extensive pharmacy industry experience with legislative policy experience in both the U.S. Congress and Texas Senate. Nathan earned his Bachelor of Science degree in Political Science from Texas Christian University and a Master’s Degree in Public Administration from the University of Houston.

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PHARMACY

Less than half of employers have specialty prior authorization programs under medical benefits, study finds

BY Alaric DeArment

PLANO, Texas — Management of specialty drugs under the medical benefit continues to trail management under the pharmacy benefit, according to a new report by the Pharmacy Benefit Management Institute.

The "2013 Specialty Drug Benefit Report," sponsored by Walgreens Specialty Pharmacy, found that 49% of employers had prior authorization programs for specialty drugs under the medical benefit, but 84% had them under the pharmacy benefit, while one-quarter of plans reported having no cost share for specialty medications under the medical benefit, and less than 20% were receiving rebates under medical, compared with 69% under pharmacy.

"At the core of this management gap is employers’ lack of visibility into the medical spend," PBMI executive director Brenda Motheral said. "Less than 1-in-4 employers reported being able to track specialty spend under the medical benefit, which is the foundation for active management."

The report was based on a survey of more than 300 employers representing 17.6 million members. It also found that more active management was observed for specialty drugs covered under the pharmacy benefit, including 44% of employers who had separate co-pay tiers for specialty drugs, compared with 36% a year ago. Meanwhile, step therapy adoption under the pharmacy benefit changed from 61% to 58%, and employers that limited specialty quantities to a 30-day supply grew from 58% to 67%. At the same time, knowledge of specialty drug management remained low, with 11% of employers self reporting a low level of understanding, along with 70% reporting a moderate level and 19% reporting a high level. Among small employers, 38% were unsure if they received specialty rebates under pharmacy, and nearly 40% of respondents overall were not sure which site of care had the lowest cost under the medical benefit. Employers also reported the greatest interest in learning more about specialty medical management and specialty co-pay assistance programs.


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Anthem suspends controversial Calif. mail-order specialty pharmacy policy

BY Alaric DeArment

NEW YORK — Anthem Blue Cross will indefinitely suspend a policy that would require many specialty pharmacy patients in California, most of them HIV patients, to receive their drugs via mail order in order to receive coverage for them, drawing criticism from patients and retail pharmacies.

In November and December, thousands of Los Angeles patients covered by Anthem Blue Cross received letters stating that starting Jan. 1, 2013, their drugs would only be covered if they obtained them through CuraScript, a mail-order pharmacy owned by PBM Express Scripts, while those who continued to use retail pharmacies would have to shoulder the full cost of their drugs. The date for the new policy to take effect was later postponed to March 1.

On Jan. 11, the consumer group Consumer Watchdog and law firm Whatley Kallas filed a class-action suit against Anthem on behalf of the patients, alleging that the policy discriminated against HIV patients by only forcing them to use mail order, while allowing other subscribers to use the pharmacies of their choice, thus violating California’s Unruh Civil Rights Act.

Calling Anthem’s decision to suspend the policy a precedent-setting action, the Law Offices of David Balto, which also had advocated on behalf of the patients, said it marked the first time consumers and pharmacies had been able to force an insurance company or PBM to reverse its mandatory mail-order policy.

"Anthem’s actions would have harmed thousands of vulnerable HIV patients, preventing them from receiving the first-rate health care they need and deserve," Balto, a former policy director for the Federal Trade Commission under the Clinton administration who brought some of the first cases against PBMs, said. "Study after study has demonstrated that pharmacies that specialize in serving HIV patients deliver better service, improve health care and lower healthcare costs. This is a landmark achievement in consumers’ and pharmacies’ ongoing battle against restrictive healthcare networks. Anthem’s decision to suspend their policy preserves patients’ choice and will need to better healthcare results."

Anthem had defended the policy, saying it would help moderate healthcare costs and saying that home delivery of prescription drugs could improve medication compliance.

"In response to feedback that has been conveyed by our members, which we are in the process of evaluating, we are delaying the March 1 changes in the specialty pharmacy program," Anthem spokesman Darrel Ng told Drug Store News. "We value the input of our members."


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