PBMs lukewarm to cost-cutting benefits of dose consolidation

Dose consolidation is receiving mixed reviews as a cost-cutting strategy, according to pharmacy benefit managers (PBMs). Although a study by Express Scripts, based in St. Louis, Mo, indicates that savings opportunities are limited, other PBMs have realized more value. With prescription drugs accounting for 10% of total healthcare expenditures according to the California Healthcare Foundation's third Health Care Costs 101 report, various cost-cutting strategies are worth exploring.

Dose-consolidation programs note that 2 doses of a drug at a certain strength cost the same per tablet/capsule as a higher-strength single dose; thus the 2 doses cost twice as much per day.

In Express Scripts' study, physicians and their patients received a letter detailing the benefits of switching from twice-daily to once-daily dosing for medications approved as once-daily doses by FDA. These include antidepressants, hypertension medications, and cholesterol-lowering medications. A randomly assigned control group did not receive letters.

Emily Cox, PhD, senior director of research for Express Scripts, said that the potential savings from dose consolidation might not be sufficient to justify the costs by plan sponsors to educate physicians and patients about moving to a once-daily dose. The changes resulting from the letter campaign did not produce enough savings.

The findings also suggested that substantial regimen discontinuation and consolidation occurring naturally during the course of drug therapy resulted in fewer opportunities for consolidation, thus producing limited savings.

Thomas Delate, PhD, clinical pharmacy research scientist for Kaiser Permanente of Colorado, former outcomes research manager for Express Scripts, and co-author of the study, said that although dose consolidation has its merits, the study produced minimal cost savings, and patients felt more comfortable making the decision about consolidating doses with their physicians than complying with a letter.

ANOTHER POINT OF VIEW

On the other hand, Cigna Pharmacy Management in Bloomfield, Conn, considers dose consolidation, along with prior authorization, step therapy, and the use of generic medications, to be a cost-containment benefit that ensures the lowest net drug cost to the member and payor. Cigna has employed the strategy for its fully insured customers since September 2001.

Although Cigna touts dose consolidation as a cost-cutting technique, it will cover the first prescription for a twice-daily dose regimen and then use the opportunity to contact physicians to recommend that they switch patients to a once-daily dose, if appropriate. Thom Stambaugh, RPh, vice president of clinical pharmacy for Cigna, said physicians have been receptive because the program saves their patients money, which is likely to make them more compliant according to nationally established guidelines.

Although Stambaugh said that dose consolidation could save patients up to 50% on prescriptions, or 10 to 20 cents PMPM, the number of patients switching to a once-daily dose is small. He also stated that even though the PBM has not measured compliance with the once-daily dose, he believes that it is easier for members to remember to take 1 pill a day.

Medco Health Solutions, a PBM in Franklin Lakes, NJ, considers dose consolidation to be a logical, clinically effective, widely accepted strategy, said Woody Eisenberg, MD, vice president and chief medical officer. Dose optimization is one of Medco's top coverage solutions and is most appropriate for medications with a long half-life. In 2005, Medco saved its plan sponsors up to 0.3% PMPM of total drug expenditure via dose consolidation.

Dr Eisenberg said that when an appropriate once-daily dose regimen is recommended to physicians over a twice-daily dose, most will follow the recommendation. Medco realized a 70% change rate during a 1-year outreach period to physicians.