Another Large Scale Research Study Confirms the Value of the Approach of Population Health Management

And here's another study, this time published in JAMA about Kaiser in Northern California that found that the following five components resulted in an increase of population-based blood pressure control: 

1. "Registry" (which the Disease Management Care Blog says is really a stand-alone database that is outside of the electronic health record);

2. "Control Rates" (which the DMCB figures is really an updated "dashboard" that displays key metrics to administrators and docs that provides feedback and helps keep everyone on the same page);

3. "Guideline" (in reality, it was a campaign to gain provider buy-in consisting of emails, publications, pocket cards, conferences, lectures and decision support);

4. "Medical assistant" follow-up operating under protocol to adjust medications (a.k.a population-based care management)

5. "Single" pill treatment (in other words, keep it simple by using pharmaceuticals that are combined in a single once a day prescription pill).

DMCB readers will not be surprised to know that the registry showed a progressive improvement in BP control (defined as less than 140/90 with the usual HEDIS® caveats) from 43.6% in 2001 to 80.4% in 2009.  Because everyone with hypertension at Kaiser was in the registry, there is no internal comparison group.  However, national and northern California HEDIS® rates for blood pressure control ranged from 55.4% to 69.4%.

While the results are 1) not necessarily generalizable outside of integrated systems like Kaiser (so we don't know for sure that this would work in a network of primary care clinics in Idaho), and 2) may have been influenced by an influx of patients with mild and easy-to-treat hypertension during the campaign), the DMCB is impressed. 

An 80% control rate for hypertension is damn good. 

The DMCB also figures that each of the interventions above are mutually supportive and even synergistic.  The whole is much greater than the sum of its parts.

How to translate this kind of success to networks of independent practices?  The answer, says the DMCB, is population health management: sponsored programs that can be owned by an insurer or a provider network that synergistically identify a population, maintain a data base, create a virtuous cycle of measurement and adjustment, get the doctors on board, deploy care managers and are smart about the pharmacy benefit.

If your a PHM service provider, vendor, consultant or stakeholder, the DMCB suggests this is one of those research papers you should bookmark, quote and aspire to.

Image from Wikipedia

Bring On The Coupons!

Most persons with insurance that includes a pharmacy benefit are probably very familiar with co-pays.  Those out-of-pocket expenses not only reduce the insurers' costs, but are a powerful tool that can incentivize the choice of a month's supply of an otherwise equivalent generic (for $5) versus an expensive brand medicine (for $30).

But suppose the brand drug manufacturer fights back with a $30 coupon?

That's the topic of this JAMA paper by David Grande. While the coupons could be prohibited as "kickbacks," can be suddenly stopped and are often given on-line in exchange for otherwise private patient information, the main argument against them is that they substantially increase insurer costs.  As a result, Dr. Grande recommends that physicians resist the allure of giving their patients any coupons and that pharmaceutical companies find other ways to reduce patients' out of pocket costs.

The DMCB has another idea that is going unmentioned by JAMA.  Why not suggest that insurers compete should against the manufacturers' coupons with their own coupons?  Competition may eat into the insurers' bottom lines but the patients will win.

Patient interests: That's the point, right?

Managed Care Pharmacists and the Medical Home: The Disease Management Care Blog Examines the Prospects for Collaboration

The Disease Management Care Blog recently had the pleasure of lecturing at the annual meeting of the Academy of Managed Care Pharmacy (AMCP). As readers may imagine, this professional organization provides advocacy, outreach and education services for persons – mostly pharmacists – involved in the pharmacy plans for health insurers. The DMCB provided an AMCP educational service by offering up a session on the merits of the chronic care model and the medical home.

While most of the 80 or so pharmacists in the room knew all about disease management, few had heard of the ‘chronic care model’ or the ‘medical home.’ In its commentary, the DMCB noted that managed care pharmacists can play an important role in helping enrollees/patients be more knowledgeable participants in their own treatment plans. A post-lecture survey indicated most of the attendees agreed the concepts of the chronic care model had merit. Thanks to the DMCB, that’s 80 more health professionals who know about the medical home.

The DMCB isn’t optimistic this will make much of a difference, however. That’s because it knows that the pharmaceutical insurance plans are typically ‘shielded’ from the standard health insurance policies that they are paired with; they are sold as a ‘rider’ with their own benefit designs, underwriting, cost structure and premiums. For an example of how this works, see here.

As a result, most of the business-as-usual pharmacy leaders that were in the room have little economic incentive to coordinate their pharmacy insurance products with all that other ‘medical stuff’ going on back home. In fact, under most circumstances, they have an incentive to ‘transfer’ their pharmacy costs to the standard insurance plan. If this sounds like health care silos at their worst, you’re right.

For example, certain injectable medicines can be administered in a physician’s office (making them eligible to be covered as a medically necessary service) or at home (making them resemble any other drug that persons need to take on their own). Given a choice, the likelihood that any pharmacist would welcome these drugs' cost into the budget is inversely proportional to their price. Yet, it is the precisely the conditions treated by the high cost injectables (such as cancer or connective tissue disorders) that may benefit from close coordination with the involvement of knowledgeable pharmacists in care management services. The pharmacists’ response? Why take on the expense of taking on any of these services when that additional cost will make their insurance product less competitive and less profitable? In fact, a really good education program could attract chronically patients, further stressing the budget.

If this reminds you of the tension between physicians and managed care insurers, you’re right. Primary care physicians have also pointed out that they’re vulnerable to taking on the cost of patient education and empowerment while the financial benefit goes to the insurance company.

And that’s not all. The DMCB has generally found that the really smart pharmacists that rise to the top of their organizations do so because they understand pharmacology, pharmacoeconomics and budgeting. These are brainy hardnosed businessmen and women who have less professional affinity for the squishy business of patient education and empowerment.

The DMCB predicts as awareness of the medical home grows, managed care pharmacists will support it if they believe it can reduce their costs. If (and that is a big if) they believe it reduces their drug spend, their support will consist of:

1) agreeing that the medical home should be covered by the standard insurance benefit, since better control of disease may reduce drug consumption, and/or

2) conducting outreach activities to primary care sites that function as medical homes.

Otherwise, the DMCB thinks it will be all talk and no action.

The only wild card? Pharmacy Benefit Managers (aka PBMs). The DMCB thinks their value as intermediaries between the pharmaceutical manufacturers and the managed care plans is becoming increasingly commoditized. Their position will become even more tenuous if price controls are pursued by the Obama Administration. To maintain their market share, expect more of them to offer not only disease management services but active support for medical homes on a 'value added' basis without any expectation of lower costs.

The Backlash Against Pharma and The Role of Disease Management

Readers may recall that several physician-leaders have recently authored an article in JAMA recommending that all professional medical associations gradually reduce pharmaceutical and device support funding - except meeting hall exhibits and journal advertising – to zero.

From time to time in the near and distant past, The Disease Management Care Blog has done business with the pharmaceutical industry. It has found the exchange to be honorable for both parties. On the other hand, while serving on Pharmacy and Therapeutics Committees and while in clinical practice, it has witnessed some troubling marketing activities. The DMCB has no easy answers on what the relationship between medicine and pharma should be, but thinks the proposed funding ban described in JAMA won’t be the final word on the matter. It thinks there’s a backlash underway. Once passions cool, a new equilibrium should emerge.

In the meantime, the DMCB was unsurprised that the proposal described above exempts the medical journals. That’s because physicians ‘can easily distinguish these marketing activities from education presentations and are free to ignore them.’ In other words, leafing through the drug ads to get to the JAMA opinion piece should have little impact on the reader.

The DMCB appreciates the irony and sympathizes with the journals’ wish to reduce their readers’ subscription costs with advertising income. On the other hand, it doubts the sponsors of these ads agree that they have little impact on the very readers that the physician-leaders are working so hard to protect from the pharmaceutical and device industry. While it could be argued that the ad content is regulated, the agency charged with that oversight has a spotty tract record. What’s more, there is evidence that journal ads that pass regulatory muster still fall short.

So the DMCB has a suggestion of its own. Since journal editors know how to edit, perhaps they should apply their skill set to developing a higher standard of truth in print advertising that they accept – such as the prominent display of vetted ‘number needed to treat’ data. Alternatively, they could also consider getting in line and falling on the sword as the professional medical organizations.

The DMCB doubts either will happen. In the meantime, the disease management organizations and Pharmacy Benefit Managers have a continuing role to play in objective, ethical and conflict-free coaching of patients and providers about the risks, benefits and alternatives to the use of medications and devices. Given all the atmospherics, however, perhaps it’s time for the industry to think about developing its own set of standards that are reasonable and free of backlash politics. Given its pedigree, the DMCB thinks it could develop a more balanced approach that could help the rest of health care out of this morass.

The Decreasing Problem of Drug-Drug Interactions Among the Elderly & the Role of PBMs, EHRs & Disease Management. Commentary on JAMA.

The Disease Management Care Blog got a holiday present from JAMA today: an article on the prevalence of major drug-drug interactions among the community dwelling elderly. This was an incredibly detailed and nationally representative study that sent researchers into persons' homes to not only ask what drugs were being taken, but the respondents were asked to go get and show the interviewers the actual drug bottles. In addition, persons were asked about over the counter (OTC) and herbal use.

91% swallowed at least one pill a day. 81% used at least one prescription medication. More than half took more than 5 different pills a day, and about 30% took 5 or more prescription drugs a day.

But what caught the DMCB's eye was the finding that 'one in 25' (or 4%) of study subjects were being exposed to a 'potential' major medication interaction. According to the authors, this corresponds to 2.2 million persons being at risk, which caught the eye of the national media here and here. Sounds like a lot.

The DMCB thinks the real newsworthiness of this report is how low the incidence is. To the DMCB's knowledge, a comparably performed study of outpatients looking specifically at drug-drug interactions doesn't exist. Only half of the drug-drug interactions in this study involved prescription drugs. Contrast that with some representative past studies: drug-drug interactions were more common at 6% in the past among Veteran's Administration outpatients, and among inpatients in Arizona the rate among admissions was 6.4%.

Unfortunately, the authors didn't ask the survey respondents if they received their drugs through an insurance plan, if their prescribing physicians used an eletronic health record (EHRs) or participated in a disease management (DM) program. That's because the data bases of pharmacy benefit managers (PBMs) are being successfully used to identify and prevent interactions. While the DMCB is no fan of EHRs in general, they are good at spotting prescription mishaps. Last but not least, disease management - using registries combined with 'live' person alerts for the prescribing physician - have also been effective in preventing injury.

The DMCB suspects the prevalence of drug-drug interactions nationwide is dropping and it thinks that's because of the market penetration of insurance coverage of medications using PBMs, clinicians' use of EHRs and the activities of DM programs. That's good news.

Post script: This JAMA article also identifies the potential for drug-OTC and drug-herbal problems, which accounted for more than half of the interactions. In the 'real' world of clinical practice, this is very hard to follow because patients (in the opinion of the DMCB) frequently change these agents. While EHRs and the practice of asking patients to tediously list every pill they use at every clinic visit (chewing up precious minutes in a high volume patient 'throughput' setting), a better approach may be covering these agents in pharmacy benefit plans. This is a radical notion, but the coverage doesn't have to be generous. In exchange for the insurance expense, the underlying PBM and DM data bases should be able to spot the other 2% of elderly individuals who are unnecessarily exposing themselves to ills from their pills. While some may be shocked, SHOCKED at the notion of insurance coverage for unproven therapies, the DMCB finds distant public policy parallels here and here.

The Obvious and Not So Obvious Ways Insurers Promote Generics (but that's not so bad)

Years ago, the Disease Management Care Blog recalls hearing a patient utter a mighty oath at his insurance company for taking his preferred blood pressure pill off formulary. ‘Not a problem,’ replied the DMCB, because it knew there were plenty of other generic pills that worked just as well. Its message to the annoyed patient: your insurance company isn’t selling what your employer bought for you. Get over it or pay your own way.

If a health insurer promotes the use of generic medications, is that good or bad? The DMCB knows that, with few exceptions, the efficacy and safety track record of generics are very high. With very few exceptions, the insurers’ preference for generics can be reconciled with the patients’ best interests. Brand drugs and generic drugs both work just as well in the vast majority of circumstances.

Clinical logic aside, is it all about money? The DMCB thinks so, but not in the way most persons understand it. When patients’ or physicians’ wishes for a ‘brand’ non-generic medication are stymied, they generally assume the high price of that drug in their particular circumstance is prompting the health insurers’ sticker-shock induced denial fever. That’s only part of the story.

Recall that insurers are all about the business of population-based risk transfer. When they sell a pharmacy benefit for a premium, they’ve already assessed the likely percentage of persons in a population that will use which drugs for what duration at which predetermined prices. So when a particular patient and their doctor chose an expensive brand medication, that behavior has already been priced in the premium.

So why deny? Insurers grow surplus by accepting risk. Anything that can mitigate that risk will be welcome. Since high utilization of pricey brand-name drugs runs the risk of losing money, a population’s anticipated medication use in the coming year can be ‘defended’ by denying coverage for the branded drugs and promoting cheaper generic medication use. In addition, there is also a sentinel effect: if physicians and patients anticipate there will be a denial, they’re more likely to choose preferred generic medications. Finally, if there are an increased number of brand prescriptions this year, that trend can foretell next years’ utilization patterns. A high trend rate means a higher premium next year, which means existing customers may flee to a lower priced competitor. A high generic utilization rate means lower prices.

In fact, the DMCB has been involved in the financial evaluation of health insurance pharmacy benefit plans. Want to know the first question you should ask if you want to know how well a pharmacy plan is being run? That’s right, it’s “What’s the generic prescribing rate?” For a taste of how critical generics can be to the price of next year’s premium, check out this report from HHS OIG about the granddaddy of all pharmacy plans: Medicare Part D.

Denials, however, are hard work. It takes personnel to man the phones and deal with disgruntled physicians and patients. It’s not only cheaper but easier to candy wrap generic promotion with other tactics such as:

Charging patients a lower co-pay for generic medications. $5 for a month’s worth of generic pills vs. $30 for the brand is an attention grabber for most consumers.

Announcing that the already low co-pays for generics will be waived in response to the bad economy. The luster of a ‘good deal’ causes patients on brand name drugs to switch, especially if money is tight. While this has the patina of social consciousness, this is really a ‘blue light’ sales special: the foregone revenue from voided co-pays pales next to the savings from reduced branded medication use. If this was all about helping patients afford their pills, ALL co-pays would be waived or reduced.

Think ‘e-prescribing’ with or without an EHR is all about patient safety? Think again. When a doc writes a paper prescription, the decision has been made. However, in e-prescribing systems, on-screen reminders and prompts have had some success in changing physician prescribing patterns toward generics before the patient walks out the door.

Mail order pharmacies, typically run by pharmacy benefit managers (PBMs) not only have the advantage of delivering pills right to the patients’ door, knowledge of their patient-customers’ addresses and telephone numbers also enables them to market generic use. That’s one way PBMs are demonstrating superior value to their real customers, the health insurers.

For an example of what doesn’t work, try appealing to physicians for their help in doing the right thing in prescribing generics as much as possible. Check out this article from JAMA showing that, while there are many publications supporting the use of generics, editorials in the peer-reviewed literature are trumping the physicians’ right to prescribe what they want when they want. Since that doesn’t work so well, better to a) pay them or b) wine and dine them, using the same approach used by pharmaceutical companies. The DMCB leaves it to its readers or members of Congress (sometimes both?) to decide if this is appropriate.

Is the obvious and not so obvious promotion of generic medications bad? The DMCB thinks the answer is ‘no,’ since we need to do everything we can to control health care costs. There is no free ride. You get what you pay for.

And a final thought for the disease management community and patient centered medical homes: an additional way to demonstrate your value is to promote generic medications whenever appropriate. You already have the patients' ear, it's the right thing to do and you'll save your customers - AND ultimately the patients - a lot of money if you're successful.

Pharmacy Benefit Managers and Disease Management

'Hello Mrs. Smith. This is John the pharmacist calling to ask how it's going with that new medicine you're taking for diabetes....'

Why is this announcement noteworthy?

The Disease Management Care Blog suspects Pharmacy Benefit Managers (PBMs), which act as intermediaries between (seller) pharmaceutical manufacturers and (buyer) managed care health insurers, will be finding it more difficult use arbitrage, volume or generics alone to maintain profitability. In this case, volume didn’t appear to meet expectations, making investors skittish about possible over-reliance on that part of the business. Hence, the PBMs’ interest in using disease management as another additional way to bring value to their customers and defend their market cap.

And why not?

Pharmacists know a lot of medical science and are trained in patient education in the course of their career. PBMs have plenty of them. It makes good sense to task a portion of them to coaching patients who are using medications for chronic illness. Plus, that’s less cost for the partnering disease management company.

What’s more, the claims turn around for pharmaceutical agents is far quicker than for medical claims (which have a ‘claims lag’ up to 3 months), are potentially more accurate and organized in huge well-run registries. That means indentifying and intervening more quickly. Disease management companies will like that, since having access to drug data for predictive modeling and to drive outcomes translates to a competitive advantage.

This is also one more example of the growing approach of a modular coordinated approach to population-based care. While this particular PBM-DM partnership looks like it’s for keeps (both companies are huge and are likely to share many clients in the future anyway), the big picture is that the PBM is now being increasingly “inserted” in the population-based care machine as one more important component.

You have to wonder why it took so long.