Sunday, January 13, 2008

Disease management’s pushing drugs!

I really like this study that was published in the latest edition of Health Affairs (full citation below).

Briefly, this was a quasi-experimental “differences in (pre-post) differences” study of the impact of a pharmacy benefit co-pay reduction versus no reduction in two self-insured employer groups, both of whom relied on the same ActiveHealth disease management organization (DMO). One employer reduced the co-pays across all tiers for some key drugs that have been indisputably shown to improve clinical outcomes in asthma, diabetes, heart disease and other conditions, while the other employer did not.

The result? Medication adherence (based on the statistically adjusted “Medication Possession Ratio” or MPR) increased approximately 2 to 4% when co-pays were reduced versus no change in the comparison employer. Except for the asthma inhaler, all the differences observed were statistically significant.

Why is this important?

While the effect size may seem modest, these changes in typical insurance settings are not only hard to achieve but could make a big difference between first and second place in a local market’s HEDIS® measures. Insurer Quality Improvement/Assurance VPs, Managers and Directors take note!

The authors are being modest when they describe this as a study of the impact of a pharmacy co-pay reduction while holding disease management (and other sources of bias) neutral. While technically correct and consistent with righteous health services research, it appears ActiveHealth notified its participants about the co-pay reduction. In other words, ActiveHealth’s remote telephony promoted the drug bargains among the patients that needed them, suggesting to me that the change in the MPR was the result of a pharmacy benefit design change combined with the DMO's services. That’s unique. True, there are other excellent studies (for example) that have shown patient coaching can increase medication use, but this was a mainstream commercial vendor program meeting the DMAA definition that was simultaneously caring for a total of 32 chronic conditions.

It’s pretty obvious that disease management and pharmacy should be coordinated, but silos predominate in this corner of health insurance “with pharmacy budgets that result in shifting of expenses from the pharmacy side to the medical side.” Seems to me that an industry with a reputation for not exceeding its customers’ expectations could use all the help it can get.

This is also a great example of the type of rigorous, transparent peer-reviewed research required of the disease management organizations if they are going to convince skeptics (ouch!) that they bring real value to the health care consumer. Quasi-experimental studies using an adequate comparator are well within their reach and they too can survive the rarefied, peer-reviewed academisphere - and in Health Affairs no less!

The authors also deserve credit for being honest about the study’s shortcomings, including the difference in the baseline MPRs between the two groups as well as other demographic differences, the possibility that other unmeasured factors accounted for the observed changes and that an increase in MPR doesn’t necessarily guarantee better clinical and financial outcomes.
Kudos to ActiveHealth and may they be blessed with increased market share for better truth in advertising.

Some captains of the managed care industry may disagree with a “reduced co-pay for some patients” approach, arguing that an equal insurance premium should provide equal coverage. I think most State Departments of Insurance would agree. On the other hand, if all health insurance enrollees have a stake in not only pooling but mitigating risk, I don’t think cross-subsidization of the right drugs for the right people is all that bad, especially when generics are not budget busting in the zero sum game. Thank goodness for flexibility afforded by ERISA and the willingness of some employers to test some important concepts.

I got to be reminded about Steppenwolf’s classic tune, The Pusher. I’m showing my age!
Citation: Chernew ME, Shah, MR, Wegh A, Rosenberg SN, Juster IA, Bosen AB, Sokol MC, Yu-Isenberg K, Fendrick AM Impact of decreasing copayment on medication adherence with a disease management environment. Health Affairs 2008;27;103-112

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