Enabling Healthy Decisions

Yesterday, a client was asking me about using incentives to motivate pharmacists to take action on behalf of the patient. I had done a pilot with a government client that had a concentration of lives in a small geography and had the majority of their prescriptions filled at one regional pharmacy chain. It seemed like the right scenario to try a program.

I wrote up a mini-case study last night which I thought I might share.

Summary:

The client decided to implement five new step therapy (i.e., the patient is required to use a lower cost generic drug prior to being able to get a higher cost brand drug) programs to go live simultaneously. We were asked to look at innovative solutions to manage the member “disruption”.

We approached the regional chain about a pilot program to reimburse pharmacists for helping patients resolve step therapy rejects at the point-of-sale. We designed a fax form for each of the five therapy classes which outlined the first-line alternatives. The objective was for each pharmacist to fax the prescribing physician using one of the five fax forms upon receiving a reject.

We agreed to pay the pharmacy/pharmacist $10 per fax sent. [Legally, we did not believe we could pay for results but simply for taking action.] We ran the pilot for 6 months and subsequently compared the amount of claims filled within the therapy class (aka GPI) after the rejects at the participating chain versus the amount of claims filled within the class at other chains for the client. We also looked at the number of prior authorizations and percentage of first line agents filled for patients that hit a step therapy reject.

Results:

At the conclusion of the pilot, we found no statistical difference between results from the participating chain versus other chains that did not participate in the pilot. In this time period, I believe we paid out approximately $20,000 for the program and concluded that this was not a solution for influencing physician behavior around plan design.

Lessons Learned:

Because of other priorities, we did not do a thorough analysis of the reasons for this not being successful (e.g., interviews with participating pharmacists), but we had numerous hypotheses about the pilot program.

1. The incentive did not actually get to the retail pharmacist from corporate and therefore the incentive was null.
2. $10 per fax was not enough, given the volume of rejects, to make a financial difference to a pharmacist making over $100K per year.
3. Pharmacists were already doing everything possible to help the patients and the incentive was simply additional cost for a task already being done.
4. Sending faxes to the physician needed to be followed up by the patient and/or pharmacist to make sure the physician acted on the request.
5. There needed to be more education from the corporate office of the retailer.
6. Patients were concerned about the follow-up. Our research had already shown that 50% of people who hit a step therapy reject don’t fill a claim, but that 90% of those that don’t fill a claim either get a sample, purchase an OTC, or pay cash for the rejected drug. (i.e., only 5% of those that hit the reject get nothing)
   

If I were to do it again, there were several things I would do differently. Trying to drive behavior at the pharmacy is a question of aligning incentives and pushing information to them through channels like the Point-of-Sale (POS) system and reject messaging. But, changing behavior has to involve physicians, consumers, and the pharmacist.

I had a chance to ride on a plane today with a man who sits on the board of a pharma company. He has worked in pharma for 30 years, and we had a good discussion. One of the things we talked about was the “arms race” in pharma to build up their number of detail representatives. Obviously this changed over the past few years especially with some of the limitations which have been placed on how pharma reps can incent physicians. We went on to talk about the challenge of physicians keeping up with all the drugs on the market and even understanding all the basic pharmacology. With over 10,000 different drugs, this is a challenge for pharmacists much more so for physicians who have other information to manage.

In discussing the topic, it reminded me of a law which exists in a few states that allows physicians and pharmacists to have a legally binding agreement around therapeutic substitution (i.e., allowing the pharmacist to change drugs or chemical entities for the patient without getting a new prescription). I can’t remember what these are called, but I threw out a new model to him that would seem very logical.

Could physicians simply write a prescription for a lipid lowering drug (aka cholesterol medication) and put the relevant diagnosis code and lab values on the prescription? The pharmacist would then be responsible for determining the right drug for the patient based on their prescription history and their benefit plan. It seems like a simple model which focuses every constituent on their primary role – the physician owns the diagnosis and care plan while the pharmacist owns the prescription selection.

It would eliminate the need for pharma reps in many ways because the conversation would be with pharmacies who use online information and have a corporate infrastructure that could have models for selection of drugs based on DUR (Drug Utilization Review – e.g., drug-drug interactions), copayments, UM (Utilization Management – e.g., step therapy, prior authorization, quantity level limits), and perhaps profit.

I talked about it last week.  Zytrec is going OTC at the end of January.  I was surprised to see that they already have shelf space (at least at Walgreens) and pricing posted.

I can’t find it posted on the web anywhere, but I believe it had a 45-day supply for $26!  For those of us that use it, that would be a great deal considering in many cases it is a non-formulary drug which a high 3rd-tier copay.