Your benefits clients may have clinical programs on their pharmacy benefit manager (PBM) shopping lists, but have you taken the time to examine how each PBM’s clinic program works?
It’s like shopping for a used car for your teenager when they get their license. Budget is important to keep in mind, but safety should be the top priority. All drivers are at risk of being in an accident, and you want to be sure your loved one is protected.
The Importance of Shopping Wisely
Imagine a PBM’s clinical programs are the car, and the plan members are the people who are going to be in that car. Your client has narrowed down the options to a 2016 sedan and a similar but less expensive 2015 model. There’s about a 10% cost difference between the two based on sticker price.
If you only cared about how much money comes out of your pocket at time of purchase, you’d get the cheaper car. But what you care about more is whether the car is safe for your loved one to drive. The 2015 model has standard airbags and the other usual, legally mandated safety features. The 2016 model has enhanced safety features, including systems meant to mitigate driver distraction and prevent accidents like automatic braking.
Do you focus on sticker price or do you prefer a car that will do more to keep the car’s driver and any occupants — like your teenager’s friends or siblings, and even you — safer when on the road?
We conduct product comparisons all the time. Why shouldn’t we do the same for something as important as PBM clinical programs, which serve as a safety net for member health?
The death rate from medication errors is nearly twice that of automobile accidents, and the costs are astronomical, both emotionally and financially. We educate ourselves when shopping for cars in order to make the best choice, so we should do the same to ensure we understand the full value of the clinical programs each PBM offers. Otherwise, we, and the employer clients, have no idea of which safety features employers forgo in the pursuit of a lower sticker price.
The Driver Behind Clinical Program Efficacy
As the car shopping example shows, we cannot afford to think of PBMs or prescription drugs only in terms of their up-front price, based on rebates and discount guarantees. We must also think of the long-term costs in terms of human life, unnecessary hospitalizations, and mounting medical bills caused by drug injury or improperly treated disease. Sound clinical programs help prevent these long-term costs, and ultimately result in better quality of life for your clients’ employees and their loved ones, and less spending overall through your clients’ prescription plans and medical plans.
The core of these clinical programs and their ability to improve patient safety is something called the drug utilization review, or DUR. When applied proactively, at the point of sale, a strong DUR program can prevent harm tied to problems such as:
- Medication errors caused by high pressure placed on providers.
- Aggressive prescription drug advertising.
- Efforts to “layer” medication to treat avoidable side effects from other medications.
One example of layering is how providers may address the problem that opioids can cause opioid-induced constipation. A prescriber may layer on a prescription to prevent constipation, rather than finding a better pain control method that doesn’t carry the constipation risk.
Point-of-sale DURs let a PBM conduct thorough evaluations of every prescription before it changes hands from pharmacist to patient. They help support these busy professionals in catching and preventing errors, so the patient receives the right medicine, at the right time, with the best chance of improving health outcomes, while reducing the risk of side effects or serious adverse events.
Unlocking Clinical Differentiators
Let’s take a look under the hood at the drug utilization review process that occurs electronically at the point of sale. A strong DUR program should consider these four significant areas of concern in a typical prescription benefit program:
- The patient.
- Inappropriate, ineffective, or harmful therapeutic medication regimens.
- Needlessly expensive medication.
- Intentional fraud and abuse.
Addressing these issues through a comprehensive DUR is vital to enhancing patient care and controlling costs. According to the Institute of Medicine, the U.S. healthcare system is wasting almost $1 trillion per year — roughly 30% of current U.S. healthcare costs.
Contributing factors include unnecessary care, tests, and procedures; ineffective or inappropriate medications; fraudulent claims; overpriced products and services; inefficient care; and failure to prevent problems that require expensive intervention. Safety issues and patient non-compliance with drug regimens can be direct consequences of inappropriate treatment and a lack of guidance and support from industry professionals.
The objective of a proactive drug utilization review is to systematically identify instances of inappropriate or questionable patterns of medication use at the point of sale, preventing problems before they occur. Doing so:
- Immediately increases patient safety.
- Enhances patient outcomes and quality of care.
- Decreases unnecessary healthcare spending.
- Prevents members from stockpiling medication.
This type of DUR checks for medication interactions, contraindications, appropriate dosage, therapeutic duplications, and refill frequency, as well as pharmacogenetic data when applicable. It should also identify members with concerning claim patterns, including those indicative of intentional fraud and abuse such as filling the same prescription multiple times at different pharmacies, or obtaining multiple prescriptions for the same controlled substance from multiple providers during a small window of time.
The DUR program flags medication for review when a claim requires a pharmacist’s attention to address any safety issues or potential fraud and abuse. When done well, the program will require a pharmacist’s acknowledgment that the issue has been resolved — if it is a matter that can be handled at the pharmacy — and the flag cannot be ignored. In some cases, the flag may simply provide a second set of eyes for the pharmacist and prescriber to prevent issues such as keystroke errors from allowing the incorrect medication or dosage strength to be dispensed. Less thorough programs allow the user to easily dismiss the flag without giving it thorough attention. This can be deadly if the patient then receives and takes a drug they were never intended to have.
Another safety vulnerability arises when a PBM’s DUR program uses alphanumerical codes to communicate with pharmacists instead of plain language. These codes can differ across systems and require the pharmacist to consult reference material to interpret them. However, when a DUR program delivers messages in clear English — for example, “SAME PHARMACY / SAME GPI, CLAIM CANNOT BE FILLED UNTIL 2020-07-24|REFILL TOO SOON” — the pharmacist immediately knows what the problem is and can easily determine next steps. This helps expedite claims review and communication with the patient and their prescriber to reach a resolution.
Drug Utilization Review and Other Clinical Programs
PBMs can use their drug utilization review process to identify claims that are subject to other clinical programs before medication can be dispensed. They can also use it to help support communication between all concerned parties when clinical programs apply. For instance, if a medication requires clinical review for prior authorization, straightforward messaging through the DUR program can help connect the dispensing pharmacist, prescriber, PBM pharmacist, and patient as part of a coordinated effort to facilitate a quick and accurate review of the claim. This helps speed patient access to a medication suited to their unique needs at the lowest net cost.
The information needed to support the authorization process will vary and can include medical charts, diagnosis, lab reports, X-ray results, genotype, and other clinical tests as applicable — such as pharmacogenetics — to assess appropriateness of the prescribed medication, dosage, and strength.
Other clinical programs are wrapped into the drug utilization review to provide additional layers of patient protection, financial value, and waste reduction. These often include:
- Drug Quantity Management: Checks that an appropriate amount of medication is being dispensed. The most accurate form of quantity management is checking the units dispensed per day supply. This ensures that patients receive neither too little nor too much of a given drug.
- Step Therapy: Requires medications be tried in series of steps. For instance, a patient may be asked to use a lower cost, clinically appropriate medication first, and only be moved to a more expensive alternative if there is a proven medical need. This helps manage healthcare costs by encouraging financially sound medication choices. It can also be used to direct patients to medications with fewer side effects, and only allow access to drugs with a higher risk profile if medical necessity is soundly established.
- Starter Dose: Restricts the initial fill of certain medications to a specific number of days. The end goal of this program is to minimize potential for waste and abuse. Candidates for a starter dose program include drugs with a high incidence of negative side effects, such as certain cancer treatments, that can result in patient non-compliance and subsequent waste from unused drug products. They also include drugs with addictive properties that can present a danger to the patient and other members of the patient’s household if unused products are left lingering in the home.
- Non-Essential Drug List: Identifies medications that have significantly less expensive alternative options available. These alternatives provide the same therapy without putting unnecessary financial burdens on the member or the plan.
- Pharmacogenetics: Incorporates metabolic data from pharmacogenetic testing to identify the safest and most effective medication for the member.
How It All Adds Up
Healthcare has become a commodity at the expense of patient and plan sponsor interests. Comprehensive, proactive clinical programs help return healthcare’s focus to where it should be — getting better results for patients and keeping care affordable for all. Plan sponsors should look for clinical programs that:
- Go beyond the patient diagnosis to examine lifestyle factors, treatment history, and potential barriers to adherence to identify the medication that offers the most value for the patient.
- Prioritize patient safety through comprehensive clinical review protocols as well as clinically driven starter dose, quantity limit, and step therapy programs.
- Place a strong focus on collaboration between all members of a patient’s healthcare team, including their primary care provider, specialists, and pharmacists, to ensure continuity of care that keeps patient safety and treatment success at the forefront.
- Apply data from pharmacogenetic testing at the point of sale to confirm the medication being prescribed will provide the anticipated results because the patient can metabolize it efficiently.
When plan sponsors partner with a PBM that utilizes effective clinical programs, they place their member’s clinical needs first. Although discounts and rebates on drug list prices are helpful in reducing costs, lasting savings depend on a reduction in unnecessary or inappropriate claims. Better clinical care also results in a healthier, more present workforce. These factors combined lead to increased client satisfaction with their prescription benefits team, including not just their PBM, but the benefits professionals who help coordinate efforts between plan sponsor and PBM to the benefit of all.
Jennifer Fuhrmann-Berger, Pharm.D., is senior vice president of clinical services at BeneCard PBF, a pharmacy benefit manager (PBM) based in Mechanicsburg, Pennsylvania.