Month: March 2016

A MAC Appeal Tale

Some of the most difficult problems pharmacists face are not clinical. The problems I am referring to are generally related to dealing with insurance plans and their corresponding Pharmacy Benefit Managers. Consider an example: We have a patient taking an older, single source medication. This patient is stable and responding well to this therapy. I should point out that this was not the drug the patient started on, and it took a lot of time to find therapy that worked well for the patient.

In early January, the prescription was adjudicated, and a MAC price was applied. The MAC based reimbursement resulted in a loss of about $1000 based on our invoice cost. The loss was still very significant after our rebates from our buying group. Shortly after this claim was adjudicated, I sent an appeal to the plan to have them revise the MAC price of 20 products, including this medication.

Before continuing, I want to warn you: this story doesn’t end in a typical manner. Much like Frederick Forsyth’s The Day of The Jackal,  I am going to tell you how the story ends before embarking on the rest of tale. Not only does plan / PBM corrects an underwater MAC price for the drug, but they actually over-correct, resulting in extreme overpayment.

When I received my response about 10 days later, the MAC price was doubled.  The response also contained a reminder:

We would like to remind you of your overall GER guarantee with [Part D Plan]. While some MAC prices may be under your acquisition cost, [Part D Plan] will ensure that you are appropriately reimbursed overall, according to agreed-upon overall generic effective rates.

Note that the patient’s drug (and most of the other 20 drugs) would still represent significant losses going forward at the new, updated rate. Not being deterred, I responded to the MAC increase notification:

To whom it may concern:

Please note I understand the contracted GER. It is my understanding, however that the contract also does not explicitly state that I can be reimbursed for product below the prevailing acquisition cost. Severely underwater MACs are never acceptible, even in the context of this contract’s terms. I require supporting documentation each of these decisions, including source and availablilty of a lower priced product on the market. Please forward these promptly. Before these MAC appeals were sumbitted, a comprehensive search was preformed revealing no available products that would support the current MAC price. Your statement to the contrary should be accompanied by supporting documentation.

The February and March claims continued to show significant losses. I did not hear back from the plan, and frankly did not expect anything more. At this point, I had done what I could, and was resigned to continue to provide this drug at a substantial loss to the patient. It would not be ethical to withhold the medication or, to refuse to stock the medication: our patients depend on us.

Unexpectedly, last week, I received another correspondence from the plan.  I do not know if the response was to my initial, or follow-up correspondence. The letter informed me that MAC price was again increased. This time, the increase was much, much higher. Reimbursement at the new rate went from abysmally low, to stratospheric levels.

Now don’t get me wrong: I have no problem making money on a prescription. In this case, however, we went from the bottom of the Mariana Trench (about 10,000 meters below sea level) to the top of Mt. Fuji. (3,776 meters high). At this rate, my losses for this drug (year to date) would quickly evaporate. Despite my elation at recouping my losses and not losing money going forward, the updated price makes as little sense as original underwater price for this drug.

What does this story say about the state of our current system? Instead of retroactively updating the previous claims to represent reasonable reimbursement going forward, the company instead overcorrected the price. It is also unfortunate that a provider had to point out the price problem in the first place. As a pharmacist, I am supposed to be focused on the patient, their drug therapy, and their therapeutic outcomes. The Plan and PBM are in charge managing reimbursement. If they were doing their job, reimbursements would not be so askew, in either direction, in the first place. Also remember, this one drug was corrected. There are still a large number that have not been addressed satisfactorily to date.

This is yet another example of our broken system. Providers have to spend time with problems outside their expected role of patient care in order to ensure they are reimbursed fairly. Reinbursement, is either feast or famine: more recently is is more famine than feast. It is a lot like climate change: we have far too many extremes and too few nice days.

Not Documented? Not Done!

The other morning, before my staff arrived to work for the day, I took a phone call from one of the group homes we service. They wanted to know if we had received an order for a dose change on a patient’s sertraline. I looked in our systems and concluded that we had not yet received an order. It turns out that I was mistaken. Deconstructing my mistake illustrates a time honored saying: If you didn’t document it, you didn’t do it!

Where’s Waldo?

Like any busy work environment, knowing where to look for information is the key to success. There are limited ways the  order in question, a prescription, can arrive:

  • A faxed in prescription
  • A mailed in prescription.
  • An electronic prescription
  • A phoned in prescription
  • A hand-written prescription brought in by the patient

Once an order has been processed, documentation should be found on the pharmacy management system (PMS). At our pharmacies, the old prescription would be discontinued, and a new prescription would be entered with the new directions. This is what I expected to find if we had processed the order.

Our pharmacy also uses a clinical documentation system, PharmClin, to document all activities as they relate to drug therapy. Any notes or pending issues related to a dose change should be documented in this system. This additional documentation is very valuable to us as it allows us to document many of the important details that complete the clinical story as they relate to the patient’s drug therapy.  PharmClin makes this information easily accessible and retrievable.

I went searching. I found no unprocessed orders. The original order on our PMS still active, and no new prescriptions for sertraline were present. There were also no notes in PharmClin related to a dose change of sertraline. In other words, I did not find Waldo. Based on a lack of evidence, we did not appear to have the order yet.

When my staff pharmacist arrived, I mentioned the call and was informed that she was aware of the order and that it had already been addressed and picked up. I was flummoxed! How could this be? As it turned out, the situation was a lot more complicated than the phone call suggested.

The Details

The patient was taking 200 mg of sertraline daily. The previous day, prescriber decided to switch the patient to escitalopram. My pharmacist correctly identified that the patient should not simply stop taking the sertraline without some attempt to taper the dosage over time and contacted the prescriber’s office. She was told that the prescriber did indeed tell the house staff to taper the dose of the sertraline and provided a flow sheet of the taper. In other words, there was no prescription written to decrease or taper the sertraline. As Homer Simpson says, DOH!

Continuous Quality Improvement

Multiple mistakes were made here. My first mistake was not asking additional questions of the house staff that called. I made the assumption that we were looking for a dose change for sertraline and failed to see the new Rx for the escitalopram. The other omissions were made before I received the call: the sertraline order was not discontinued in the PMS, and the communication with the prescriber was not documented in PharmClin.

The scenario above an epidemic in today’s healthcare environment. The patient is told something by a primary provider, and other providers do not receive notice. The communication from the prescriber to the pharmacy, a form of documentation, was missing. Despite this, my staff pharmacist who dealt with the problem discovered all of the details after they spent time on the problem the previous day. But like the first omission, her documentation was incomplete and largely missing.

Having an tool like PharmClin to document clinical interventions is a great asset to a pharmacy. But if the tool is not used, the benefits are lost. Pharmacists across the country make outstanding interventions every day. The fact is, however, that they largely fail to document their work. In a small pharmacy with few employees, mentally keeping track of issues like this might be manageable, but eventually the system will fail. In a larger pharmacy with many more employees and patients, a systematic documentation system is a must. Remember…Do It. Document it. Done! This is how you can make every encounter count!

 

 

Follow-up: The System is Broken.

Many practitioners, both prescribers and pharmacists, responded to Tuesday’s article The System is Broken. Most were in agreement with the frustrations described, and many had experienced similar issues with their own patients. Some pointed out that the immediate release guanfacine’s labeled indications only include hypertension while the extended-release guanfacine, a more expensive formulation, is indicated for ADHD. This is an excellent point. It likely explains PBMs rejection of the prior authorization requested by the prescriber. It is also an excellent example of the need for practitioners and PBMs alike to use clinical judgement.

It is about the Patient

So why would the prescriber have ordered the immediate release guanfacine 1 mg twice a day instead of the a once-a-day 2 mg extended release version? The answer is simple: you treat the patient, not the monograph. Is the patient receiving safe therapy, is the therapy effective, and are they achieving the desired therapeutic outcomes? In the case here, then patient has been stable on the therapy for quite some time and has been achieving their therapeutic goals. It was only a change in insurance (a new Medicare Part D plan) that occurred on January first that precipitated the problem.

The resolution to the problem was to change the patient’s therapy to meet the PBMs arbitrary rules. This change, however, has consequence:

  • The patient will require additional monitoring (which will likely include visits additional office visits to the prescriber) to ensure the change continues to achieve the therapeutic goals.
  • The extended release version of the medication, while being available generically, costs significantly more (in excess of $200 per year) than the immediate release version.

To summarize: the patient was to be moved to a different version of the same drug based only on the existence of an official indication. The PBM applied little, if any clinical judgement (a fact that is further highlighted by their recommendation to use metoprolol,  a beta blocker, for hypertension when the patient was already taking atenolol). What is worse, the PBM is not responsible for added costs to patient care that resulted from the change: Medicare Part B will shoulder these costs. Not only does this change cost Medicare Part B, it also costs the drug plan (Medicare Part D) more.

So remember: treat the patient, not the symptoms. Medicine and pharmacy are much more than memorizing and applying recipes. Our patients are real people. We have to think. Follow the simple mantra of  Is the patient receiving safe therapy, is the therapy effective, and are they achieving the desired therapeutic outcomes? Doing this is one more way to make every encounter count!

The System is Broken

For the past month we have been working with one our psychiatrists who is treating a mutual patient of ours. This patient has an intellectual disability, lives in a group home, and has significant history of depression with anxiety and attention deficit hyperactivity disorder (ADHD). One of his mediations that he has been taking for over five years is guanfacine. As we have tried to fill this medication for him, the PBM has rejected the claim because the PBM wants him to try a first line agent for hypertension. Herein lies the problem. The psychiatrist’s office has sent in different prior authorizations (PA) informing the PBM the reason the patient is taking guanfacine. Here, the guanfacine is for the treatment of ADHD, and not treatment of hypertension. Each time the PA has been denied, and each time the PBM directs the psychiatrist to use a first line antihypertensive, such has amlodipine, atenolol, or benazapril. What makes this even more frustrating is the fact that this patient also has hypertension and he is being successfully treated with metoprolol.

So my question is “Who makes these decisions?” First, we have a patient whose ADHD has been stable on a medication—guanfacine, the drug is relatively inexpensive, and it has been proven effective. Secondly, if the PBM is really watching over the patient and their medication profile, then why would they recommend a beta blocker (atenolol) when the patient is already taking a beta blocker (metoprolol). To be honest, this is why providers (prescribers and pharmacists) become frustrated with the system—the PBM is not taking the time to look at the individual case and, in fact, is making recommendations that are harmful to the patient.

The patient is frustrated, the psychiatrist is frustrated, and we are frustrated. We will not withhold treatment for this patient, but we have to trudge through the murk and mire of the system set up by the PBM who “supposedly” hires clinical pharmacists to monitor these situations and make clinical decisions. I am not so sure this is the case and, if so, the clinical pharmacist fell asleep at the wheel with this patient. So we become the one who is left “holding the bill”. The system takes up valuable time from both the prescriber’s office and the pharmacy which is time that is taken away caring for other patients.

It is time for a system overhaul. The current system is broken, does not optimize patient care, and penalizes the providers, in the trenches, who are actually caring for the patients. In fact, the relationship between the PBMs and providers has become antagonistic. If we use the current case as our example, what else can we provide to the PBM with regard to the patient’s clinical record to receive an appropriate clinical decision? As a health care provider, I am liable for the decisions that I make regarding my patients and their drug therapies. I take responsibility for the decisions that I do make, which means that I assume the risk as well. PBMs should also be liable for their decisions, because, as this case example demonstrates, their clinical carelessness can have negative consequences for the patient.

As our health care system embraces quality performance, and providers are being held to certain standards of care. Third party administrators (TPAs) such as PBMs should also be held to the same standards. This requires better systems,  improving the communication between providers and PBMs. A reasonable start might simply be provider access to a live person—preferably someone who is clinically trained, and a reduction in the length of time for decisions regarding medication coverage to be made. We need to remember the adage, “Its all about the Patient” as we look for ways to improve the system. Right now it seems to be anything but the patient!

 

Is There Anything Special About the 90 Day Supply?

The other day, I received an email notice from a Medicare Part D PBM: [highlight style=”yellow,”]UPDATE: You have Cases[/highlight]. The message continued on to state:

30-90 Conversion with $50 Payment for Positive Outcome

I will be the first to admit that when I read case, I immediately thought of a clinical opportunity. The conversion of a prescription from a 30 day supply to a 90 day supply does not really implement any of the myriad of clinical skills I have accumulated over the years. What is more interesting is the remuneration being offered: $50 for a successful conversion (Note: I am assuming that a successful conversion means a single one-payment for converting all maintenance medications to 90 day supplies). A complete medication review (CMR) earns us about $60—only about $10 more—while taking significantly more time and requiring actual clinical expertise. The value being attached to the conversation to extended-day supplies by the PBM begs the question, what is so special about the 90 day supply?

Spoiler alert: there is nothing special about 90 day supplies. To understand why, one has to consider the plan’s motives. For a company, motive generally comes down to one thing: money. Either the plan makes more money when 90 day fills are used, or it costs them less money. Logic supports both assertions; the PBM often pays the pharmacy less for a 90 day supply (a lower markup on the drug and lower, or even zero, dispensing fee). But this doesn’t really explain the significant incentive being offered. I believe that there is more to this story. I believe that the motive includes the Medicare Star Ratings program. The plan stands to receive significant rewards from Medicare for attaining a 5 star rating.

Currently, the Medicare Star Rating system contains four active measures, and one display measure. Three of the five measures focus on patient compliance over three therapeutic categories: ACE / ARBs, Diabetic Meds, and Statins. High risk medications is the fourth measure. The fifth measure, Comprehensive Medication Review completion rate, CMR, became a full measure this year. The current display measure is Statin use in Diabetes, which may eventually become an active measure.

The PBM itself has few mechanisms to impact any of the Star Measures; it is the network pharmacies the PBM uses that are able to influence the PBMs Star Measure scores. Anything that the PBM can do, including incentives paid to the pharmacies or other tactics, to improve the measured compliance for the patients enrolled in their plan will likely impact its bottom line. Compliance is difficult to directly measure without significant effort. Because of this, surrogate measures of compliance are used by Medicare. Two methods of estimating compliance are Mean Possession Rate (MPR) and the Percentage of Days Covered (PDC). Medicare is using the PDC as the basis for the Star Measures involving compliance. A quick literature search reveals there are articles describing increases in MPR and PDC for patients receiving 90 day fills.

I searched for and found several different recent studies on 90 day supplies. Many health plans and payors pointed to a single article (reference 1 below) done by CVS health when discussing 90 day fills for their covered lives. Another often referenced publication (reference 2 below) was done in collaboration with Walgreens. Another PBM, OptumRx, also published a short study evaluating the impact of 90 day fills on compliance.  The conclusions of each study showed “improved adherence” when 90 day supplies were issued.

Interestingly, each of these three publications either explicitly state or infer scheduled, or automatic refills. In other words, the prescriptions were refilled every 90 days without respect to a request by the patient. This has long been a technique use by mail order pharmacies. By not studying the patient’s at will refill requests, the results show significant bias. Automatically filling prescriptions will inflate MPR and PDC without actually impacting compliance. The surrogate measure has essentially been subverted. The same increase in MPR or PDC could be accomplished by automatically refilling / mailing the prescription at any arbitrary interval.

So let’s circle back to the beginning, with the case opportunity to convert patents to 90 day supplies. Our pharmacy has exceeded the CMS threshold for PDC based Star Measures since day the measures were first published. We are routinely in the top 20% nationally with respect to our Medicare patients’ PDC based measures in all three categories. We have done very, very well despite having only a small minority of patients receiving 90 day fills. In fact, we have found that we are able to keep much better track of our patients’ compliance seeing them every 30 days. We have significantly more engagement with our 30 day patients than our 90 day patients.

So in a nutshell, I don’t believe that the 90 day supply is special in most cases. In fact, I consider 90 day fills to be a more of a negative influence on patient care. Not only are pharmacies paid less for both the drug and our effort for a 90 day supply, but our ability to engage with and monitor our patients is also significantly diminished. Make no mistake, I do believe that, if one of the reasons for this 90 day incentive program was to impact compliance, it is a move in the right direction. It is be a promising development, and additional evidence that the PBMs are looking to pay pharmacies for high performance. I simply believe that the program, as such is mis-directed. I would prefer to have PBMs pay an incentive for exceeding the CMS threshold levels for the Star Measures than simply pay a one time reward to move patients to 90 day fills.

References

  1. Community Pharmacy Automatic Refill Program Improves Adherence to Maintenance Therapy and Reduces Wasted Medication.
  2. Medication Days’ Supply, Adherence, Wastage, and Cost Among Chronic Patients in Medicaid

  3. New adherence study: 90-day Home delivery beats 90-day retail

Compliance: Working the Numbers of PDC

Every month I await the e-mail from PQA telling me that my latest EQuIPP scores are ready. If I want to impact my scores, I need to understand the numbers behind them. Today I thought I would remind everyone how the EQuIPP compliance score, the PDC or Percentage of Days Covered, is calculated for a pharmacy.

While compliance might seem like an easy topic, it is far more complicated: compliance for patients is aggregated into a score representing the overall compliance of all patients in the pharmacy. Several assumptions are being made in order to do this.

Defining Patient Compliance

If I miss a dose once a month, most would consider me compliant. But what about missing one a week? A line needs to be drawn somewhere, and EQuIPP has arbitrarily drawn this line at 80% of days covered. This means that someone missing 5 or fewer days worth of medication in an average month is considered compliant. According to PQA, compliance is a binary (YES / NO) attribute. Either the patient is compliant, or they are not compliant, in any given month.

But EQuIPP cannot tell if a patient takes a drug 80% of the time. They are relegated to using claims data. Percentage of Days Covered (PDC) is calculated based on dispensing data from the pharmacy. PDC accounts for early or late refills by looking at the total number of days worth of drug the patient has in their possession during a period of time. For example, if a patient fills a 30 day supply of medication, and then refills the prescription 25 days later (5 days early) the second month, and 40 days later (10 days late) the third month, the PDC would be calculated based on the previous two fills as:

60 days of medication / 65 days elapsed * 100 = 92% — Based on the EQuIPP definition, the patient is compliant.

Note that the assumption is that the patient is out of medication when the refill is processed. This assumption can create erroneous calculations when used over short periods of time. In the example above, this assumption may actually overstate compliance as the patient has only taken 50 days worth of medication in 65 days and was just picking up a refill before going on vacation. It can take several months for the PDC to stabilize and more accurately reflect patient compliance. This creates additional questions for which I don’t have good answers.  For example: what is the start date for the calculation? For a new patient to the plan, it will be their first fill date after they enter the plan. But for a patient that did not change plans, how far back is the first fill date? I am assuming that the PDC is using calculating compliance over some defined period of time, probably 6 to 12 months.

Defining Compliance for the Pharmacy

Every patient included in the EQuIPP measures will be labeled as either Compliant or Non-Compliant for a given month. From this pool of patients, the pharmacy’s compliance rate is calculated. This is simply the number of compliant patients over the total number of patients. A rolling 6 month average of this calculation is the number seen in the EQuiPP dashboard.

Improving Your Measure

As many have observed, the easiest way to impact a pharmacy’s PDC for a given drug category is to target patients just falling short of the 80% threshold for compliance. Consider a pharmacy with a Diabetes PDC score of 80% with 100 patients enrolled. The CMS threshold for this measure is currently 82% and the Top 20% threshold is 92.5%. In order to move the pharmacy above the CMS threshold, two patients that are currently non-compliant need to become compliant. Likewise, moving 13 patients into compliance will move the pharmacy into the top 20%. Targeting patients with compliance between 75-79% will have the best chance for quick and easy success for the pharmacy.

To do this, a pharmacy has to identify the low hanging fruits: the patients falling just short of 80% compliance. The EQuIPP platform has the capability to show you outliers, but in practice, we have not found this very useful. Other products (Mevesi, PrescribeWellness,  McKesson and others), have platforms to help you identify the outliers. These tools are retrospective in nature because they generally use data that is pulled from your dispensing system at regular intervals. All of these tools are designed to be used outside the dispensing workflow to create a list of potential patients to target.  Once you have the list, you need an implementation plan to put the data to work. Other tools, like PharmClin, flag patients during the dispensing workflow, allowing you to target the patient in real time, avoiding the need for additional implementation. I prefer real-time identification of patients for two reasons: it takes less time and effort to identify the patients needing targeting and the data is always current. 

Taking Action

If you are starting with a list of targets, you will need a battle plan. One possible tactic is to place a note or flag on the patient record to alert the pharmacist or technician that the patient is a target when they initiate a new prescription or refill. This allows the pharmacy staff to approach the patient at the time they pick-up the medications. Another method is to contact patients outside the prescription workflow by appointment or by phone. Ultimately, the goal is to initiate a conversation with the patient.

At this point, with the patient in front of me or on the phone, I tend to be careful with how I proceed. Remember, claims data gives us very little real information. The patient may not actually be non-compliant: they may have a very valid reason for their compliance history. For this reason, I always try to be neutral when starting a compliance conversation. I might ask, for example:

I see that your refills for metformin are less frequent that I would expect. Has the dose the doctor wants you to take changed?

We often find perfectly reasonable reasons for PDC based compliance problems. Physician samples, dose changes not communicated to the pharmacy, and alternative drug supplies are commonly seen explanations found in our practice. If the dose has changed, we can fix the compliance problem by getting a new prescription from the prescriber. For other explanations, I simply document the intervention with the patient and revisit compliance in 3 months. Our use of the clinical documentation system PharmClin makes the this easy and automatically allows us to schedule a follow-up for the problem.

Sometimes, I find that the patient doesn’t tolerate the drug well, and has backed off of the dose as a result. The physician may have instructed the patient to do this temporarily, with instructions to gradually increase the dose. Metformin is a common example. Finding this, I work with the patient and prescriber to ensure that the patient achieves the desired outcome without unnecessary effects. This might mean helping the patient with their gradual dose increase, or recommending a different drug entirely. Either way, the “compliance” problem can be both documented and successfully addressed.

Addressing Non-Compliance

Most pharmacies use a medication synchronization program to address compliance problems. While this is a valid plan, it is most appropriate in the case that a patient forgets to order refills or stop in to pick up refills. I am careful and investigate a host of other possible reasons that the patient doesn’t refill their prescription on time before asking them if they are interested in synchronization.  Again, I proceed with caution. Is the reason financial? Might the reason be related to the time of administration or restrictions on what can or cannot be taken with the medication? I work hard to understand the reasons before creating a patient specific plan. If the issue is financial, finding a less expensive alternative might be needed. If the patient simply struggles with getting to the pharmacy, offering our delivery service is a reasonable intervention. Finally, if the patient forgets to order refills or has difficulty remembering to pick up medications at the pharmacy, the benefits of synchronization are a great way to help the patient become more compliant.

MedSync

One final note about medication synchronization. While this tool can be very successful in addressing compliance issues, the reasons for its success in our pharmacy are not what you might think. Filling a prescription on a regular frequency will, of course, correct the claims based PDC score. But in our pharmacy, med synchronization’s success comes from the increased level of engagement our staff have with the patient. By calling the patient each month, we can ascertain if any changes have been made and gather important informant about any problems the patient is experiencing. Additionally, we are able to approach the patient about other topics including what their therapeutic outcomes are and if they are meeting them. In short, we work hard to make every encounter count!