Consumer-driven pharmacy plans must focus on compliance and safety

A recent survey by the Employee Benefit Research Institute found that 70% of those enrolled in consumer-directed health plans (CDHP) say that they consider costs when deciding to see a doctor or filling a prescription as compared with fewer than 40% of those in a comprehensive plan. However, the survey also found that CDHP enrollees were twice as likely to avoid, skip or delay healthcare services because of costs (35%) than were those in a comprehensive plan (17%).

Benefit sponsors need to be concerned about non-compliance with essential medications and treatments. In addition to protecting the health and safety of the beneficiary, plans will want to avoid the negative financial consequences of added medical services and lost productivity that can result from poor adherence.

The extent to which medication non-adherence leads to higher overall medical costs was illustrated in a 2005 study by Medco Health Solutions, Inc. showing improved medication adherence is associated with significant medical savings due to fewer hospitalizations and emergency room and doctor visits. In this study, every additional dollar spent on medication for diabetes patients was associated with approximately $7 in medical savings. CDH pharmacy benefit sponsors should encourage and support patient adherence to their prescription care plan. Patient outcomes and costs can be significantly improved when pharmacy benefit sponsors provide information and tools to help patients adhere to their pharmacy treatments.

This is especially true for prescription drugs. In 2003, the average number of prescriptions filled was slightly more than 21 per household. When it comes to making medication choices, the right decisions can mean high quality prescription care at lower costs to the consumer, while the wrong decisions can lead to impaired health for the patient and greater overall medical costs for the provider.

The management tools and practices that support the CDH prescription drug benefit impact patient decisions and ultimately affect adherence as well. Having a pharmacy specialist implement the prescription drug component of the benefit can help ensure the highest level of care by providing the full-range of plan management, clinical, and educational tools needed to promote drug compliance among consumer directed plan members.

The level of clinical expertise that a pharmacy specialist brings to the table is essential to a CDH pharmacy plan, one that few medical carriers can provide. Safety systems such as drug utilization review (DUR) and integrated data programs help identify compliance issues and communicate with physicians and patients to alert them that the medication regimen is not being properly adhered to.

However, compliance is only one potential prescription drug problem. DUR programs alert pharmacists, at the time of filling a prescription, if a drug should not be prescribed with another medication the patient is taking or if the dose is inappropriate or should not be prescribed because of the patient's age or gender.

An integrated data system, such as Medco's RationalMed Patient Safety System reviews pharmacy, medical, and lab, and patient self-reported data to detect potential problems that may exist between a prescribed drug and a patient's health condition and alerts physicians so that they can make a therapy change if necessary. These safety systems can substantially decrease costs that would be incurred through related medical-services or hospitalization – costs that could drain the resources of members and plan sponsors alike.

Pharmacy specialists can also be more effective at encouraging formulary compliance and the use of lower cost alternatives, such as generics. A CDH pharmacy plan should be pulling out all the stops to encourage the use of generics whenever clinically appropriate. Generic drugs not only cost substantially less, but they also promote drug compliance. A recent study in The Archives of Internal Medicine found that patients who took a generic drug had close to a 13% increase in drug therapy adherence, compared with patients who took brand name third-tier drugs covered by their plan.

Education is a key component to promoting generics usage among CDHP members. According to the 2005 Medco Monitor consumer survey by Yankelovich, despite a growing willingness to take generic drugs, most Americans are not very knowledgeable about them. To increase their knowledge, generic drug information should be easily accessible to members and provided through various channels, including the Internet and direct mail.