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Title: UKCMC MANAGED CARE PHARMACY WORK GROUP RECOMMENDATIONS Approved by the UK College of Pharmacy Executive Committee


1
UKCMCMANAGED CARE PHARMACY WORK GROUP
RECOMMENDATIONS Approved by the UK College of
Pharmacy Executive Committee
  • 9/18/01 Edition

2
Current Issues
  • Therapeutic medication breakthroughs continue
  • Rapidly escalating drug costs/expenditures
  • 15-20 per year, Kentucky rate one of the highest
    in the US
  • UKHMO was 19.7 in FY01
  • PMPY Plan Cost went from 296.75 (99-00) to
    355.21 (00-01)
  • Expected to double in 5 years
  • Greater societal dependence on drug therapy for
    treatment and prevention of disease
  • Promotion of high cost drugs by pharmaceutical
    manufacturers
  • Rising health insurance premiums and co-payments
    for pharmaceuticals
  • Employee dissatisfaction with costs and perceived
    benefit reduction
  • Inattention to the problem by practitioners and
    lack of involvement in addressing these issues

3
Utilizing Increasing
4
Utilization Increasing Another Slice of the Data
5
Cost Per Prescription Rising
6
Managed Care Pharmacy Work Group
  • Problem StatementWhat recommendation or
    information can the UK College of Pharmacy and
    faculty provide to assist in maximizing
    medication effectiveness and economic efficiency?
  • Goals
  • Reduce rate of escalating drug cost trends
  • Reduce impact of drug costs on co-payments and
    premiums in FY03
  • Establish and educate individuals in controlling
    cost / quality of care (long term)
  • Incorporate cost effective utilization of
    pharmaceuticals into future role of College of
    Pharmacy
  • Promote the Best Practice in pharmacotherapy
    and pharmacoeconomics

7
In Which Aspects Can the College of Pharmacy
Contribute?
  • Expertise in drug therapy, consultation on
    coverage
  • Pharma-Copay-Therapy Clinic - collaborative
    effort with medical staff
  • Programs and research projects targeted to reduce
    managed care expenses
  • Educational tools (computer support, dedicated
    time)
  • Conduct C.E. programs to target UK Physicians and
    UK-HMO
  • Development of a data warehouse to support best
    practice in drug use, treatment
    options/guidelines
  • Medication use strategies, creation of a
    Medication Use Management Center
  • Potential to contract with UK-HMO in risk-sharing
    agreement for cost-reduction
  • Commitment and dedication to the project
  • Integrate cost-effective therapy as an active
    part of College mission/curriculum and
    pharmacists role

8
Outline for Presentation of a Plan
College of Pharmacy Contribution
Co-payment/Member Cost Sharing Modification
Preventive Service Offerings
Medication Use Strategies
Consumer Advertising Solutions
Academic Detailing Solutions
Drug Sample Solutions
Which options should be pursued? What are the
next steps?
9
Co-Payment/Member Cost Sharing Strategy
Modification
10
Health Plan Coverage of Pharmaceuticals
Full Coverage
No Coverage
Co-Payment Coverage
  • UK has opted to utilize the co-payment coverage
    option for pharmaceutical benefits in the UK-HMO
    and PPO products.

11
UK-HMO Prescription Co-Payment Coverage Options
Tiered Generic, Preferred,
Non-Preferred Few Non-Covered Diagnosis
Flat Rate Not Recommended
Co-Payment Coverage
Tiered Generic, Preferred, Non-Preferred
Non- Covered Dx Expanded Non- Formulary
Sliding Percentage Rate (Or mix with Tiered)
12
UK-HMO Prescription Co-Payment Current Coverage
Option
This is our current structure, however there are
options that remain that lead to
escalating prescription drug costs 1. Should
the non-preferred drugs be discouraged
by a larger differential in costs? 2.
Are too many drugs covered? 3. Are
generic drugs promoted? 4. The co-payments
have been adjusted to 8, 20 and 40. Can
we drive drug therapy to the lower co-pay drugs
(generic and preferred)?
Tiered Generic, Preferred,
Non-Preferred Few Non-Covered
Diagnosis
Co-Payment Coverage
13
UK-HMO Prescription Co-Payment Recommended
Coverage Option
  • This strategy could result in lower overall drug
    costs.
  • More drugs could be moved to a non-formulary
    status.
  • Change the Certificate of
  • Coverage to add a
  • non-formulary status.
  • 2. Will the system be
  • responsive to
  • changes?
  • 3. Is support present
  • throughout the
  • enterprise?
  • 4. Is medical staff willing
  • to make adaptations?

Co-Payment Coverage
Tiered Generic, Preferred, Non-Preferred
Non- Covered Dx Expanded Non-Formulary
14
Member / UK-HMO Cost Sharing for 2000-2001 Plan
Year
15
UK-HMO Prescription Co-Payment Alternative
Coverage Option
This strategy could result in lower overall drug
costs. Some managed care plans are experimenting
with this option. 1. Generally perceived
as a reduction in benefits. 2.
An example would be 10 for generic,
25 for brand and 50 for
non-preferred with caps for each
type. 3. Not recommended at this
time.
Co-Payment Coverage
Sliding Percentage Rate (Or mix with Tiered)
16
Branded Product Costs Rising
17
Generic Costs Not Rising As Fast
18
Medication Use Strategies
19
Medication Use Strategies
  • Review therapeutic drug groups with specific
    activities targeted to that group
  • Focus on high cost drug categories
  • Use Proton Pump Inhibitors (PPIs) as a pilot for
    program
  • Evaluate potential for Selective Serotonin
    Reuptake Inhibitors (SSRIs) or lipotropic agents
    (Statins)
  • Develop a structure/strategy accepted within the
    UKCMC enterprise
  • Program must be approved by the UK Managed Care
    Committee and Clinical Board prior to
    implementation

20
Medication Use Strategies
21
UKHMO Where are the drug costs rising?
22
Medication Use Strategies
  • Proton Pump Inhibitor (PPI) Program Example
  • Dosing Should dosing (QD versus BID) and
    utilization undergo closer scrutiny?
  • Duration Should a three month plan limit be
    placed on PPI therapy?
  • Selection Change
  • Should a step down to H-2 Antagonists (generic)
    be required for duration of therapy greater than
    3 months?
  • Should antacids be advocated?
  • Should use of pantoprazole (Protonix) be required
    if a PPI is prescribed?
  • Effective July 1, pantoprazole is preferred but
    the others are available as non-preferred should
    they be non-formulary?
  • Lifestyle Modification Should these be promoted?
  • Educational components for prescribers and
    patients
  • Cost avoidance estimates can be projected if this
    option is to be pursued

23
Estimated PPI Overuse (2001 dollars)
Patients requiring PPIs gt3 months
Patients requiring PPIs lt 3 months
Estimated overuse of PPIs
24
Academic Detailing Solutions
25
Academic Detailing Solutions
  • Formulary pocket guide
  • Counter-detailing teams
  • Targeted CE Programs
  • Provider feedback on utilization rates

26
Academic Detailing Solutions
  • Formulary Pocket Guide
  • PLAN DESCRIPTION
  • Develop global formulary guides (all plans)
  • Distribute printed pocket guides and PDA download
    version (via website access)
  • Target certain providers (i.e. residents)
  • Pro-active selection of the plan drugs
  • CRITICAL SUCCESS FACTOR(S)
  • Ease and availability of web site update design /
    designer

27
Academic Detailing Solutions
  • Counter-Detailing Teams
  • PLAN DESCRIPTION
  • Assign team(s) of detailers according to
    therapeutic category
  • Team may consist of students, residents, faculty
    and pharmacists w/DI center assistance
  • Teams would develop detail pieces to inform
    providers of evidence-based practices and
    medication costs
  • Teams would plan regular times for face-to-face
    discussion with providers
  • Communication piece is left with the prescriber
  • Communication via email to providers or via web
    site
  • Points to be emphasized Efficacy, Safety,
    Cost-effectiveness
  • CRITICAL SUCCESS FACTOR(S) Manpower and
    distribution of effort and targeting certain
    provider groups and drug classes first

28
Academic Detailing Solutions
  • Internal CE Programs
  • PLAN DESCRIPTION
  • Counter detail teams and CE office would develop
    programs
  • Programs would be given at grand round seminars,
    resident noon conference, etc.
  • Programs could be available on website
  • Target medical and pharmacy staffs
  • Expand training to Kroger pharmacists if
    applicable
  • CRITICAL SUCCESS FACTOR(S)
  • Institutional support for programs
  • Manpower availability to create and provide
    programs

29
Academic Detailing Solutions
  • Provider Feedback on Utilization Rate
  • PLAN DESCRIPTION
  • Develop reports on prescriber utilization
  • Present by department (peer) and by individual
    prescriber to the medical staff
  • Create accountability of prescribing habits
  • Provide financial incentives for good utilization
    rates (tied to departmental or division
    performance)
  • CRITICAL SUCCESS FACTOR(S)
  • Ensure accuracy of prescribing data
  • Physician buy-in of program

30
Drug Sample Solutions
31
Drug Sample Solutions
  • Pharmacy Coordinated Samples
  • Generic Samples
  • Restrict Pharmaceutical Representative Access
    within Clinics

32
Drug Sample Solutions
  • Pharmacy Coordinated Samples
  • PLAN DESCRIPTION
  • Central location for storing and distributing all
    samples
  • Pharmacist will dispense samples like regular
    prescriptions
  • Records can be kept about medication use by
    specific patients and prescribers
  • Patient education about new medication including
    co-pay information
  • Pharmacist may intervene before dispensing
    samples to ensure cost-effective utilization
  • Funding for pharmacy could be provided from
    pharmaceutical companies
  • CRITICAL SUCCESS FACTOR(S)
  • Global institutional support
  • Space/location
  • Manpower for staffing

33
Drug Sample Solutions
  • Generic Samples (UKHMO Funded Starter
    Prescriptions)
  • PLAN DESCRIPTION
  • Provide some low-cost generic drugs as samples in
    the clinic (ex. ibuprofen, enalapril, metoprolol,
    amoxicillin, hydrochlorothiazide)
  • Samples provided through sample pharmacy with
    label
  • Up to a month supply
  • Incorporate access to these samples with
    counter-detailing pieces about generic
    utilization
  • CRITICAL SUCCESS FACTOR(S)
  • Funding to provide starter prescriptions

34
Drug Sample Solutions
  • Restrict Pharmaceutical Representative Access
    within Clinics
  • PLAN DESCRIPTION
  • Develop sign-in and sign-out policy
  • Utilize badge ID system
  • Set limits on time allowed in clinic during any
    given week or month
  • Set a policy for all industry sponsored lunches
    and events
  • Restrict or ban promotion of non-approved
    products including information and samples
  • CRITICAL SUCCESS FACTOR(S)
  • Universal agreement to action and policy
    enforcement from Clinical Board
  • Alternative control information and sample
    dissemination

35
Consumer Advertising Solutions
36
Direct to Consumer Advertising(Jan to Sept 2000)
Scott-Levin DTC Advertising Audit and
Competitive Media Reporting, Third Quarter 2000
37
Consumer Advertising Solutions
  • Pharma-Copay-Therapy Clinic
  • Direct Patient Mailers
  • Update Website Information and Access
  • Kentucky Clinic Pharmacy Labels and Bag Stuffers

38
Consumer Advertising Solutions
  • Pharma- Copay-Therapy Clinic
  • PLAN DESCRIPTION
  • Pharmacist clinic
  • Create a Kentucky Clinic Pharmacy Model
  • Help center for UKHMO patients to get advice on
    how to reduce out of pocket expense for drugs
    (and reduced Plan costs)
  • May be staffed by students, residents, faculty,
    and pharmacists
  • Set certain clinic days and make appointments
  • Expand to Kroger Pharmacies after a model is
    established
  • CRITICAL SUCCESS FACTOR(S)
  • Institutional support
  • Clinic staffing and space

39
Consumer Advertising Solutions
  • Direct Patient Mailers
  • PLAN DESCRIPTION
  • Use the PBM system to informally identify
    patients
  • Send mailer about reducing out-of-pocket expenses
    by discussing with their provider the formulary
    alternatives
  • Target top 3-4 classes of drugs
  • Utilize advertising within KCP - Bag stuffer
    information dissemination
  • Develop other mailers to educate patients
  • Ask their providers if this medication is covered
    on insurance? What does generic mean?
    Can I ask for generic prescriptions from my
    provider? Why do drugs cost so much?
    How much is my insurance really paying?
  • CRITICAL SUCCESS FACTOR(S)
  • Manpower to develop the information
  • Must stay within patient confidentiality
    guidelines

40
Consumer Advertising Solutions
  • Update Website Information and Access
  • PLAN DESCRIPTION
  • Include a reduce your co-pay section
  • Include an ask the pharmacist section
  • e-mail questions about medications or how to
    reduce monthly out-of-pocket expenses
  • DI center may be able to respond
  • Include the formulary guide and PDA download
  • Commonly asked drug questions (FAQs)
  • Add CE pieces
  • Place website access shortcut on all desktops in
    clinic
  • CRITICAL SUCCESS FACTOR(S)
  • Ease and availability of web site update design
    and designer
  • Must stay within patient confidentiality
    guidelines

41
Consumer Advertising Solutions
  • Kentucky Clinic Pharmacy Labels and Bag Stuffers
  • PLAN DESCRIPTION
  • Include drug specific messaging focus on
    wellness or disease of the month
  • Promote web site, include value added information
  • Identify drug costs on prescription bag
  • Expand to Kroger pharmacies after the model is
    established
  • CRITICAL SUCCESS FACTOR(S)
  • Counter direct to consumer advertising
  • Utilize monthly contact to promote cost-effective
    drug use

42
Preventive Service Offerings
43
Preventive Service Offerings
  • Partner with UK Wellness to integrate
    pharmaceutical information with Wellness
    information
  • Provide health service information upon
    dispensing
  • Pro-active long term solution
  • Example Pharmacy coordinated smoking cessation
    program initiated in 2000

44
Preventive Service Offerings
Identify Patient
Health Improvement and Management Program /
Clinic
Management
Prevention
  • Self managed
  • Lifestyle modifications
  • Education
  • Lifestyle modifications
  • Professionally managed
  • acute and chronic episodes of care
  • DSM, MD and RPh interventions

45
Program Implementation Timeline
Provider Feedback on Utilization Rate
Intro of Non-Formulary Status
Begin Medication Use Strategies
Pharma-Copay-Therapy Clinic
KCP Labels and Bag Stuffers
Begin Targeted CE Programs
Restrict Pharm Sales Reps
Update Website Information
Preventive Service Offerings
Integration into Curriculum
Formulary Pocket Guide
Increase Website Access
Finalize Long-Term Plan
Direct Patient Mailers
Drug Sample Pharmacy
Counter Detailing Teams
Short-Term Plan
Generic Samples
September
1 - 3 months
3 - 6 months
6 - 12 months
46
UK Managed Care Pharmacy Work Group
  • John Armitstead, MS, RPh, Chair
  • Margaret Nowak-Rapp, PharmD
  • Bryan Yeager, PharmD
  • Robert Littrell, PharmD
  • Robert Kuhn, PharmD
  • Alan Zillich, PharmD
  • Eric Millheim, PharmD
  • Kelly Smith, PharmD
  • Julie Davis, PharmD (Resident)
  • Kim Mitchell, PharmD Student
  • Allen Woodward, MD (Advisory)
  • Ken Roberts, PhD (Advisory)

Approved by UK College of Pharmacy Executive
Committee 7/12/01 Presented to UK Managed Care
Committee 7/24/01 Presented to Chancellor
Holsinger 8/13/01
47
The College of Pharmacy Contribution
College of Pharmacy Contribution
Co-payment/Member Cost Sharing Modification
Preventive Service Offerings
Medication Use Strategies
Consumer Advertising Solutions
Academic Detailing Solutions
Drug Sample Solutions
48
Next Steps?
  • Which of the recommendations are feasible?
  • Which actions require medical staff buy-in?
  • Which pharmacy staff members should be assigned
    to each recommendation?
  • Which recommendations can be implemented in Plan
    Year 2002, 2003?
  • Further review
  • UK Managed Care Committee in August for Budget
    Review
  • Clinical Board in September
  • UK Health Benefits Task Force in September
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