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.
