New PBM program focuses on high-risk patients


Prescription Solutions starts program that combines pharmacy and medical data to identify high-cost patients



New PBM program focuses on high-risk patients

Pharmacy benefit manager Prescription Solutions has launched its first pharmacy-based program to focus on high-risk patients. The Pharmacy Care Management Program (PCMP) pilot combines medical and pharmacy claims data to identify patients at highest risk for a catastrophic event.

The program is based on the premise that 5% of a plan's population consumes 50% of costs. "Many disease management programs consist of patient education," said Patricia Cruz, managed care clinical pharmacist at Sun Health MediSun. The Phoenix-area Medicare+Choice plan is working with Prescription Solutions to test PCMP. "We're doing more by increasing pharmacist-patient contact," she said.

Prescription Solutions combs Sun Health claims data to identify patients at highest risk for congestive heart failure (CHF) and osteoarthritis (OA). With an average patient age of 75, Cruz said, both conditions are common in her 13,500-patient population.

About 23% of potential PCMP patients have opted in, said Brian Funk, Prescription Solutions' clinical pharmacist for program implementation. He is looking for 300 CHF patients and 200 OA patients for the 18-month program that began in April.

PCMP pharmacists call the patients to review their condition, drug regimen, and compliance. The interviews take 30 to 45 minutes, Funk said. The R.Ph. completes a report on each patient, including suggestions for any changes in therapy, patient education, and compliance reminders. Reports go to the patient's physician for review and action. A second phone interview reviews and reinforces education and compliance messages.

"Pharmacy data let us identify patients who are noncompliant with their drug regimen," Cruz said. "Claims data also show duplication of therapy and regimens that are not on target or are too high for elderly populations. Since both diseases can be controlled with drug therapy, the pharmacist is the natural person to guide the intervention."

Pharmaceutical manufacturers are paying for PCMP, since drug utilization increases with disease management, Funk said. If the program is successful, Prescription Solutions will offer similar programs to other clients.

Neither Sun Health nor Prescription Solutions is talking about projected savings, but both expect a significant return on investment. The PBM points to a 10:1 payback on the cost of boosting beta-blocker compliance among postmyocardial infarct patients.

That kind of payoff is no surprise to PBMs already selling similar programs. Wellpoint Pharmacy Management has been mining pharmacy and medical claims to identify high-risk patients for Blue Cross programs and health maintenance organizations in California and other states since 1999.

What began as a single pilot in one therapeutic area has expanded to commercial-scale products covering 12 diseases. "Success with our Therapy Management product depends on the client population and quality of data we have to work with," said Brian Sweet, Wellpoint Pharmacy Management v.p.-clinical pharmacy services. Wellpoint identified noncompliant patients on antidepressants for a client covering 180,000 lives. Reminders boosted compliance rates from 57% in a matched control group to 75% in the intervention group.

Wellpoint usually calls on pharmaceutical manufacturers to cover Therapy Management costs. In most cases, Sweet said, the PBM uses multiple sponsors to avoid bias, or the appearance of bias, in its analysis and intervention recommendations. Physicians are almost uniformly supportive, he added. "They recognize that we can give them more effective clinical tools to manage their riskiest patients."

AdvancePCS gets similar support for its five-year-old Building Better Health program that integrates medical, pharmacy, and laboratory claims. Interventions run the gamut from informational direct mail to telephone interviews, remote monitoring and data collection, and regular follow-up contacts.

"We have been able to show significant improvements in the quality of care with three datapoints—a baseline and two successive years," said Pam Hightower, assistant v.p. for disease management at AdvancePCS. "Costs are usually in the pennies per thousand lives." Plan sponsors foot the bill directly for some programs. In other cases, drugmakers or product rebates cover the costs. Either way, clients see the value in screening their population for risk status in diabetes, asthma, CHF, hypertension, and other disease states.

Managed care organizations can tailor programs to support the quality-improvement measures set by the National Committee for Quality Assurance. "We're adding to their ability to meet quality requirements for NCQA accreditation," noted Baze Vaziri, assistant v.p., AdvancePCS Analytics, which designs Building Better Health programs. Employers also like risk-stratification programs, he said, even though companies generally bear most of the costs. "Plan sponsors understand, especially if they have a retiree population, that an investment up front pays off big in the long run," he said. "On their own, companies just don't have the tools to provide this level of care."

Fred Gebhart


Fred Gebhart. New PBM program focuses on high-risk patients.

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