Utilization management programs may increase appropriate use of medication and quality of healthcare

Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. The company is headquartered in St. Paul, Minn., and manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to nearly 20 million members, offering clinical services for people with complex medical conditions. Prime is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans.

BACKGROUND

Health insurers and payers are increasingly using utilization management (UM) programs to encourage safe and cost-effective medication use. Some utilization management programs use prior authorization (PA), a program that requires members to meet certain criteria before particular drugs are covered under the health plan.

Health insurers and payers are increasingly using these programs to help ensure patients receive the safest and most-effective treatment and to prevent prescribing that is improper or suboptimal for a specific health condition. In addition, PA programs often apply to certain high-cost drugs and/or drugs that have the potential for misuse, and this can help to reduce escalating healthcare costs. Before medications included in the PA program can be covered under a benefit plan, the doctor will need to get approval through payers or insurers.

EXPERIENCE

Prime recently presented 2 studies at the Academy of Managed Care Pharmacy (AMCP)’s 25th Annual meeting & Expo in San Diego that conclude that utilization management programs may increase the quality of healthcare for patients taking specialty medications.

In the first study, Prime evaluated utilization patterns for natalizumab (Tysabri), a drug FDA approved for Crohn’s disease and relapsing forms of multiple sclerosis (MS). Natalizumab exposes patients to the risk of developing progressive multifocal leukoencephalopathy, a rare viral disease that damages the brain and is often fatal. As a result, natalizumab is, in general, only prescribed when the patient has had an inadequate response to or is unable to tolerate an alternative MS therapy.

Prime looked at integrated medical and pharmacy claims among 8.1 million commercially insured members. All members using natalizumab had an MS diagnosis. Researchers found that during the 6-month analysis period, more than half (50.7%) of the patients starting on natalizumab had not tried an alternate MS medication. The percent of members with no alternate MS agent decreased to 39.0% and 26.3% for 24 and 60 months look back, respectively.

Given that 1 in 4 patients hadn’t tried another MS treatment prior to natalizumab, Prime concluded that a PA program could be successful in better determining safe and appropriate treatment for patients with MS.

In a similar study, Prime researchers, in collaboration with Florida Blue, evaluated use of linezolid (Zyvox), an antibiotic that the Infectious Disease Society of America recommends should not be used as a first-line treatment for most infections. The society recommends linezolid be reserved to treat drug-resistant strains of enterococcus, staphylococcus, or streptococcus.

In the study, 1.2 million members were exposed to the PA and another 1.1 million members were not. The study found that after 30 days of follow up, the average per member overall costs of care were $4,189 lower for members exposed to the PA submitting a linezolid claim (P=.020). Members submitting a linezolid claim not exposed to the PA had a non-significant 2.8% lower hospitalization rate (P=.582), 3.9% higher ER visit rate (P=.467), and, on average, 1 additional office visit (P=.332) than those who were exposed to the PA program.

Researchers concluded that the linezolid PA program helped ensure appropriate use of the drug and did not negatively impacting patient outcomes.

Dr Johnson

Steven V. Johnson, PharmD, BCPS, is senior director of health outcomes at Prime.