Managed Care - August 2008 - (Page 13) MEDICATION MANAGEMENT The most common cause of therapeutic duplication is when two doctors are prescribing medications for the same patient. Another cause is when a doctor changes from one medication to another within the same therapeutic class, but the patient doesn’t discontinue the first medication. For Schedule IV drugs, the problem may be fraud resulting from “doctor shopping.” “Fraud is certainly not the cause in the large majority of cases,” says Morris. “Lack of patient education is the most common cause.” “Whatever the cause, an individual may end up taking two drugs with similar actions, which could lead to serious side effects,” says Aetna’s Gregory. The company’s recent internal study found more than 4,800 incidents of possible therapeutic duplication in the statin class among Aetna members . Of those, pharmacists avoided filling 3,500 duplicate prescriptions. Given the success of its statin program at the dispensing level, Aetna is expanding the therapeutic duplication program to include the following drug classes: • Selective serotonin reuptake inhibitor (SSRI) antidepressants • Proton pump inhibitors used to treat ulcers • Tryptamine-based drugs used to treat migraine headaches WellPoint is also expanding its program. Morris points to the fact each drug class has specific problems related to therapeutic duplication. With SSRIs, for example, patients may be switching drugs prematurely. “It takes about six months for an antidepressant drug to take effect,” she says. “Physicians may be moving their patient to a new drug too quickly because of reports of unpleasant side effects, or patients may be getting different drugs from different doctors.” In addition to analyzing claims for therapeutic duplication within a class, WellPoint looks for drugs with the same ingredients. “With opioids and many antipsychotics, the issues often relate to overutilization, and that creates its own set of problems,” she says. “We place a strong emphasis on retrospective evaluation and intervention with these drugs.” So does Cigna. Its data mining for therapeutic duplication in those classes can actually lead to treatment referrals, says Stambaugh. Building on past experience The Aetna program at the pharmacist level built on an existing program named Rx Check, which analyzes member prescription claims a few days after a prescription is filled. That program has had significant results: • 68 percent of doctors who received Rx Check letters discontinued the simultaneous use of drugs that serve the same purpose; • 51 percent of doctors reduced the number of prescriptions written for certain medications with the potential for misuse; • 28 percent of doctors reduced the multiple daily dosing of a proton pump inhibitor to a single daily dose when appropriate, or discontinued the use of the medication. Rx Check reviewed 5 million drug claims every month, filed by more than 5.5 million members, resulting in more than $25 million in annual savings, according to Aetna. “Examining those results, we decided that investing in the technology necessary to address therapeutic duplication at the prescribing level made good sense,” says Gregory. Regular review “Claims data are reviewed regularly for controlled substances, such as narcotics and medications used to treat psychiatric conditions, to identify the potential for intentional or unintentional overuse or misuse,” says Stambaugh. “Programs related to those diagnoses are typically safety focused, targeting cases when a person may be going to multiple physicians and pharmacies to obtain and fill those prescriptions. Because we are integrated with a behavioral health company, we can work with the individual and attending physician to help that person.” MC AUGUST 2008 / MANAGED CARE 13
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