Managed Care - August 2008 - (Page 12) MEDICATION MANAGEMENT Reducing Therapeutic Duplication Successful at the Dispensing Level New technology is helping health plans address the problems of polypharmacy By Martin Sipkoff I n the last 18 months, claims data mining by several health plans and pharmacy benefit management companies has led to significant reductions in therapeutic duplication within drug classes, especially statins. Although return-on-investment figures are not yet available — several plans are studying the savings resulting from their programs — the improved quality of care related to addressing therapeutic duplication is well established, say plan and PBM officials. “Reducing therapeutic duplication at the dispensing level is definitely cost effective. Based on earlier experience at the prescriber level, we are certain it results in improved outcomes,” says Robert Gregory, RPh, head of clinical programs at Aetna Pharmacy Management. At the beginning of last year, his PBM began a program that resulted in a 70 percent reduction in dispensing of duplicate statins for members enrolled in its fully insured products, according to an internal study. “We are certain enough of its effectiveness to begin expanding the program to other drug classes at the pharmacist level,” says Gregory. Claim software has made prospective utilization reviews for specific drugs, especially Schedule IV narcotics, more prevalent in recent years. State Medicaid programs are, in fact, mandated by federal law to conduct prospective drug utilization reviews (DURs), although the level of prior authorization differs dramatically from state to state, according to a study by the Health Policy Studies Division of the National Association of Governors. What is new is that increasingly sophisticated technology offers the ability for payers, especially the PBMs that manage millions of prescriptions a month, to prospectively evaluate claims at the pharmacy level by drug class, such as statins — and to avoid prescription duplication within that therapeutic class before a drug is dispensed. Aetna’s claim system alerts pharmacists that therapeutic duplication may be occurring, and pharmacists then determine whether both medications are necessary or one should be discontinued. More of a problem This is particularly valuable as a quality measure in today’s health environment because patients are increasingly seeing several physicians and filling their prescriptions at several pharmacies. And as the population ages, polypharmacy is becoming increasingly prevalent — another factor in therapeutic duplication. “Patients are increasingly moving away from the primary care physician model of care,” says Lisa Morris, RPh, director of quality improvement and safety for the PBM WellPoint NextRx, which began a statin program last year. “We knew there needed to be a process that ensures as much due diligence as possible at the dispensing level.” Cigna’s claim processing system also allows for real-time drug reviews at the dispensing level. Pharmacists are notified when a prescription is being processed that may duplicate a drug already being taken by the patient; when a day’s supply exceeds plan limits or the limit recommended by the drug manufacturer; and when prescriptions are being refilled too soon. “The broader the network of pharmacies that are connected to a PBM’s claim processing system, the greater potential for drug reviews to improve safety,” says Thom Stambaugh, RPh, chief pharmacy officer for Cigna Pharmacy Management. “Identification of duplicate prescriptions can be a flag that the member may be taking too much of a medication.” Contributing Editor Martin Sipkoff is a long-time health care journalist. 12 MANAGED CARE / AUGUST 2008
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