Out of the Silo: Designing a Pharmaceutical Benefit

that Encourages and Monitors Adherence to Evidence-Based Practice

Authored by:  Alan R. Zwerner, MD, JD

Chief Medical Officer

The pharmaceutical benefit -- together with real-time pharmaceutical claims data --  is a powerful tool with which to encourage patient (and physician) adherence to evidenced-based medical practices.

Numerous studies demonstrate poor compliance with prescribed pharmaceutical regimens, especially medications for chronic conditions and health risk factors. Very few people who require life-long medications, for example, take their drugs as prescribed over the years. Renewal and refill data indicate large gaps in therapy which prevent patients from realizing the full value of pharmaceuticals, and few physicians or employers are addressing the problem.

Currently, most pharmaceutical benefit packages are aimed at minimizing over-utilization. They attempt to reduce the number of units consumed while driving physicians and patients toward products with a low unit price. If the employee returns to the pharmacy “too early” for a renewal or prescription refill, he is told to come back in a few days. This is a one-sided approach that evaluates the total cost of pharmaceuticals in a silo. It neglects the benefit of appropriately prescribed, dispensed, renewed, and properly utilized drugs.

In addition, it focuses on pharmaceutical claims information technology as a tool to limit “improper” access, and not as a tool to detect, facilitate, and encourage compliance. If we truly believe in these therapies and their ability to prevent further deterioration in health while maintaining or improving functionality, we must cease our current asymmetrical approach to the pharmaceutical benefit and the narrow way in which pharmaceutical claims information is used.

The Quality of Pharmaceutical Claims Data
Medical claims data generally are poor and dated. We all have lived with its profound limitations. Pharmacy claims data, by contrast  are, accurate and contemporaneous. We can generally conclude, based on prescription information, what condition or disease is being treated and whether or not medication refill and renewal data indicate compliance with recommended pharmaceutical regimens. In short, pharmacy claims data are good data.

Some Possibilities

There are many creative ways to design the benefit and utilize data to encourage adherence. One way to encourage employees to take their chronic care medications as directed would be to reduce the co-pay for refills or renewals at the proper time.  Many benefit packages discourage people from refilling chronic care medications "too early".  This may discourage some employees from taking their medication without interruption.  Extending this "refill window" can encourage patient compliance. Another example would be to award one prescription refill or renewal without a co-pay after one year of medication compliance.

Refills and renewals could be monitored contemporaneously, with automatic notices sent to pharmacists, physicians, or employees when deadlines are not met. Physicians or pharmacists who agree to receive such notifications, and who act upon them in real time, might be rewarded for doing so. There are numerous such “pay for performance” opportunities.
 

The Future
Once we have designed a drug benefit that encourages proper prescribing and adherence, we can measure the correlation between evidence-based pharmaceutical utilization and employee disease and risk progression, other health services utilization and cost, and functional outcomes. We can start examining and utilizing the wealth of information available to us in pharmaceutical data, and continue to optimize the pharmaceutical benefit to encourage the patient behavior we want.

We can begin to take pharmaceutical utilization out of its current silo and treat it as not merely an expense, but as a cost-effective investment to help forestall risk and disease progression, improve employee health, and reduce total health related costs.

In Summary -- The HPM Value Chain, below,

concisely shows how benefit design can translate into improved worker productivity.

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Dr. Alan Zwerner was appointed Chief Medical Officer of the Institute for Health and Productivity Management in June 2004.  Dr. Zwerner is a nationally recognized physician, attorney, lecturer, author, and executive who has worked more than 30 years with physicians, pharmaceutical companies, health plans, healthcare purchasers, and patients.  By helping bring new and creative tools to healthcare professionals, at the point of care, he helps transform information into usable knowledge that improves patient care.  Zwerner, now an independent healthcare consultant, formerly served as the senior vice president of Health Net, president and CEO of The Medical Quality Commission, a research, accreditation, and educational organization; vice president of medical-legal affairs at Unified Medical Group Association, a medical group trade association; and senior vice president of PersonalMD, a healthcare technology company. Previously, he practiced obstetrics and gynecology for 10 years and law for three years. Dr. Zwerner has lectured at some of the nation’s leading universities, including The Wharton School, Yale and UC Berkeley, and has been interviewed frequently on major television networks.  Dr, Zwerner  received his bachelors degree in molecular biology from State University of New York at Buffalo, earned his M.D. from Georgetown University School of Medicine and completed his residency at the George Washington University Medical Center.  He then earned a J.D. from Western New England School of Law.