Month: December 2016

Over the last two or three months, we have been observing an accelerating pace of critical news stores focusing the business practices of both the PBM industry and Drug Manufacturers. Now, Rueters is reporting that twenty states are suing Mylan and Teva over drug pricing. Knowing what I do about lawsuits, it will be quite some time before this is resolved, but I would not be surprised if the PBM industry and drug wholesalers are soon included in this type of action. In many ways, the story of greed and corruption in the drug industry is starting to resesmble a line of dominoes, each one falling on the next.

To read the Rueters story, point your browser of choice to U.S. states sue Mylan, Teva, others for fixing drug prices.

Among the topics regularly covered on the Thriving Pharmacist are several articles discussing rewards for performance paid to pharmacies. Few of the examples shared here, unfortunately, are actually representative of pay for performance. Today, I will share yet another pay-for-performance program that misses the mark.

This program is regional, and is called Intervention Messaging, or IMRx. It is designed to increase medication adherence using real time alerts sent to the pharmacy during the claim adjudication cycle.  The plan is supposed to benefit both the patient and the pharmacy by paying the pharmacy an incentive fee for each adherence conversation they have with the patient. Payment is dependent on the patient filling the offending (late, unfilled) maintenance prescription.

Like most programs, there are positive benefits to the pharmacy:

• The incentive payment is welcome revenue
• The pharmacy should see additional fills, which adds additional revenue
• The pharmacy’s adherence measures should be positively impacted, assuming the medication flagged by the program falls in an EQuIPP category.

These are all true, and one cannot contest the positives. But the program misses the point. It only addresses a problem after it has occurred. If a pharmacy successfully addresses the noncompliance , the reward becomes a one-time bonus unless the patient falls back into non-compliance. A pharmacy that is  proactive with adherence management, using MedSync and motivational interviewing techniques to ensure high levels of patient compliance, would see no reward for their work and high performance.

There should be two parts to any performance incentive: an incentive to improve, and an incentive to maintain high performance. This program, like many that have come before it, fails to address the last part. Just like pharmacists caring for patients, the performance incentive programs need to make every encounter count.

 

This year’s Medicare Part D open enrollment (which ends on Dec. 7th) has turned out to be one of the more interesting  since the program was rolled out more than a decade ago. Previously I reported that our pharmacies elected to drop preferred status with one of the more aggressive plans for 2017. The plan we dropped was very proactive, and called patients to let them know that their current pharmacy would not be preferred next year.

Many patients that received these calls contacted us wanting clarification and guidance. They did not want to change pharmacies, but many were left with the impression from the call that they had to change. As I previously wrote, this was not necessarily accurate: there are often several options available. We quickly recognized that if we did nothing, we stood to lose patients unnecessarily. We immediately developed a plan to address this new challenge.

The first thing we did was to identify all of the patients using the plan in question. In all, we had about 200 patients on the plans representing a small but significant percentage of our active patient population. Next, we eliminated all of the dual-eligible patients from the list. These patients receive assistance on their premiums and copays, and the preferred status of their pharmacy does not impact the out of pocket costs to these patients. That left about 100 patients for us to contact.

We started making calls, offering to answer questions and perform plan reviews for each patient. Within about two weeks, we were able to call and schedule most of these patients. Once we had the patient in front of us, we had to determine which type of plan the patient was on: a plain Prescription Drug Plan (PDP) or a Medicare Advantage plan with a PDP (MA-PDP). From here, we used iMedicare, a third-party service to help up quickly outline all of the options available to each patient. The options available depended on the type of plan they were currently enrolled with: PDP or MA-PDP.

Prescription Drug Plans (PDPs)

Patients with simple prescription drug plans were very easy to help. While our pharmacies will not preferred in 2017 for the patient’s current plan, there are several plans that are very competitive in 2017 in which we are preferred. In fact, in almost every case, the patient was better off switching plans than switching pharmacies. These were the low hanging fruit, and we are confident we will be able to maintain all of these patients going into the new year.

Medicare Advantage Plans (MA-PDPs)

Patients using a MA-PDP create a more difficult challenge for the non-preferred pharmacy. These programs bundle both the Medicare benefit along with a prescription drug plan. In our region, there are only a few companies offering MA-PDPs compared to more than 30 PDPs. To complicate matters, the drug expense is only one part of the plan, making it much more complicated to compare different MA-PDPs for the patient. This is, unfortunately, best left for the insurance agent.

But this does not mean that making an appointment with these individuals is a waste of time. In fact, it was a great opportunity to discuss exactly what the cost associated with pharmacy choice actually would be for the patient. The end results varied, but can be divided into two categories:

1. The patient would pay an less than an extra $240/year to use our pharmacy instead of a preferred pharmacy. That amounts to less than $20/month
2. The patient would pay more than $240/year to use a non-preferred pharmacy. Sometimes the additional cost was more than $1000!

There are a variety of reasons a patient might fall into either of the above categories. For example, a patient reaching the catastrophic coverage phase of the plan would often end up in the first category. There is little difference at that point between preferred and non-preferred pharmacies. Other patients, taking a more expensive generic medication or brand medication found that copays were very comparable between preferred and non-preferred pharmacies. Again, these often ended up in the first bin. Conversely, we did find several individuals taking medication combinations that would cost them more than $100/month more to use a non-preferred pharmacy. It is hard to justify spending over $1000 more for pharmacy choice. There were patients several falling into this group.

In almost every case, the patient planned to continue to use the Medicare Advantage plan in which they were currently enrolled. Only a few were going to consider other plans. I wish I could report that we were able to maintain all of these patients, but that would have been an unrealistic goal. That being said, we did manage to maintain a significant number. As it turns out, many of the customers placed significant value in their pharmacy choice. In the end, if the difference was less than $240/year, we stood a good chance of maintaining the patient.

In the end, we expect to maintain more than 90% of our customers we targeted. Many chose to switch their PDP, and others were fine paying a small premium to stay with their chosen pharmacy. In the end, I think it is safe to say we made every encounter count!