Short-cycle prescribing puts a lid on medication waste

Key Points

With more and more costly drugs breaking the bank for patients and payers, managed care organizations are developing programs to reduce a small niche of waste associated with early discontinuation of medication therapy. For example, a plan might reimburse for a full supply of a drug, which might be later discarded by a patient after only 1 dose. Managing this waste is an opportunity for added savings.

Express Scripts estimates such pharmacy-related waste will exceed $1.2 trillion between 2010 and 2014. Last year it exceeded $403 billion.

"Challenges such as side effects can result in a portion of medication going to waste," said Rhonda Letwin, RN, director, specialty reporting and analytics, Walgreen's Specialty Pharmacy.

"Patients new to these drugs often find the medication dosing and administration instructions to be complex," she said. "Because there is less physician oversight of self-administered oral chemotherapies compared with intravenous chemotherapies, there may be a delay before a physician is made aware of a patient experiencing medication side effects and resultant nonadherence."

Waste in specialty pharmacy is more apparent than for other drugs.

"If a patient throws away half of a $20,000 prescription that is not proving effective, it is noticeable," said Matt Totterdale, vice president of specialty pharmacy for Express Scripts.

He said stakeholders have to coordinate benefits across a spectrum of care, integrate information technology systems across sites, and provide an "uber set of data," despite the variety of information generated by providers.

Express Scripts relies on its medical benefit management program, which combines utilization and reimbursement management for appropriate drug use. "The idea is to blow all the waste out of the system, not just move it from one place to another," he said.

Walgreens Specialty Pharmacy created its Oral Oncology Cycle Management Program to support patients who take certain oral chemotherapy drugs. Pharmacists and oncology nurses contact patients at predetermined intervals during their first month of therapy to assess the patients' behaviors. Nurses educate them about potential side effects and confirm medication adherence.

If an adverse event is noted, the team responds according to established protocols and contacts the physician as necessary, Letwin said. The evaluation can lead to changes in medication therapy regimens or discontinuation of therapy without medication waste. At the conclusion of the first month of therapy, physicians receive a report that details the date the patient started and stopped therapy, adverse reactions or side effects, and interventions performed on the patient's behalf.

The oral oncology drug program manages 3 medications-Nexavar (sorafenib), Sutent (sunitinib), and Tarceva (erlotinib)-chosen because of their high toxicity levels and high cost. Participants include all patients who are new to the therapies and receive the 3 drugs through one of Walgreens' central dispensing facilities. The latest results, collected over 31 months, translate to a potential of $2.1 million in savings if all patients had participated in the monitored dispensing option and improved rates of persistency with their therapy during the initial fills. The increase in persistency reflects the benefits of access to clinical support between physician office visits, Letwin said.

Regence Rx, a PBM in Portland, Ore., contracts Walgreens as its preferred specialty pharmacy. Lynn Nishida, director, pharmacy services for Regence Rx, said its strategy helps to mitigate waste as pharmacists work with members and their physicians to dispense smaller quantities if appropriate. "We avoid disincentives for [the lower quantity] supply by charging only a portion of the copayment," Nishida said.

APPROPRIATE USE OF DRUGS

Medco Health Solutions sponsors a similar program, called the First Cycle Optimization Program that uses therapy management protocols to support patients and minimize drug waste.

"Following evidence-based therapy recommendations ensures that drugs are only used in situations where clinical benefit is expected," said Milayna Subar, MD, vice president and national practice leader, Medco's Oncology Therapeutic Resource Center. "Ensuring that patients have a clear understanding of how and when to take a medication, as well as expected side effects, is a key to preventing waste."

If there is a loss of life during the first cycle of treatment, Medco will reimburse 50% of the cost of select oral chemotherapy medications to plan sponsors enrolled in an exclusive dispensing program with the PBM.

In April, the Centers for Medicare & Medicaid Services postponed a ruling that would require long-term care facilities, which serve Medicare Part D members, to dispense oral brand-name prescription drugs in 7-day increments in order to reduce waste from unused medications. The time period has been extended to 14 days or less and will go into effect in 2013.

"We are concerned that 7 days will cost 4 times more to deliver drugs, require additional labor, and may even result in deploying expensive technology," said William Popomaronis, vice president, National Community Pharmacists Association. NCPA's primary objection to the original rule is the lack of evidence supporting any savings from 7-day dispensing.