| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
|
|
|
|||||||
|
|||||||||
TRACK to:
|
|
Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Re: Improving prescribing behavior may require additional incentives
Progress since 2000 in the NC Medicaid Pharmacy Program
Improving prescribing behavior may require additional incentives
|
|
|||
|
Winton G. Gibbons, Chicago, IL USA Equity Analyst---William Blair & Company, LLC
Send response to journal:
|
The USDA Economic Research Service reports that in 2002 the disposable income in the United States was about $7.8 trillion, with expenditures on food of $790 billion, alcohol $112 billion, tobacco $88 billion and drugs $162 billion ($49 billion out of pocket--40% of that spent on alcohol and 50% that spent on tobacco). According to the CDC, from 1900 to 2000 life expectancy increased from 47 to 77 years old, certainly much of which results from improvements in safety and nutrition, not to mention vaccinations and basic antibiotics. However, it appears to me that branded pharmaceuticals and biologics play an ever increasing role in continuing this trend, but despite being something so vital in all our lives, it is really a small part of the country's total spend. So while drug prices may certainly have areas of inefficiency, and while certain programs or budgets may have their own constraints or be in crisis, are we in danger of throwing out the baby with the bath water by missing the big picture as it relates to therapeutics? I propose that the demand for improved health is rational and should be accepted, so the debate should move from trying to micromanage costs (although of course remaining prudent in our spending) to bringing in resources spent elsewhere, for example tobacco and alcohol as a start. Competing interests: No support or direct ownership, but I recommend therapeutic stocks as part of my job |
|||
|
|
|||
|
L . Allen Dobson ,Jr. MD FAAFP, Concord, NC, USA President, Cabarrus Family Medicine and Director of GME, Northeast Medical Center
Send response to journal:
|
The issue of rising pharmacy costs raised by Drs Fink & Byrns(1) is a problem plaguing most state Medicaid programs. In 2004, NC pharmacy expenditures have risen to more than $1.48 billion dollars annually(2) . This increase, as pointed out in the article, is multi-factorial, caused by increasing number of recipients, increased use of new and expensive medicines but in many cases wasteful use of resources by providers. Many states, in an attempt to slow expenditure growth in their pharmacy programs, have instituted broad regulatory efforts such as Prior Approval, or restrictive formularies (Preferred Drug Lists). These broadly applied approaches, while effective in reducing pharmacy costs are rather “blunt instruments” in changing prescriber behavior. At the same time, there is little data about how such approaches affect the total health care costs of the patients with diseases the restricted drugs are used to treat. Since the study period, NC has implemented a targeted approach to controlling pharmacy costs. Initial efforts included generic conversion, Maximum Allowable Cost (MAC) pricing for multi-source drugs, and 90 -day prescriptions for generic, non-controlled maintenance medicines. These initiatives have saved an estimated $80 million per year. Recent policy change allows the coverage of selected OTC medications by prescription such as Prilosec OTC, Claritin OTC, selected laratadine OTC preparations thereby giving the physician less expensive alternatives in two costly classes of medication. A major effort in 2004 has been the development of tools that utilize evidenced based information and data to identify opportunities to modify expensive utilization of drugs. The tools utilized are 1) a limited Prior Approval program, 2) the Prescription Advantage List (PAL), a voluntary program that educates prescribers about the relative net costs of medications within the 10 most expensive classes to NC Medicaid. 3) a Specialty Disease Registry that monitors costly drugs used in special disease states and 4) an Active Intervention program which utilizes peer – peer intervention where data identifies variance from expected prescribing patterns for specific physicians or patients. The PA process is estimated to have saved $ 8 million in 2003-4 while the PAL will save an estimated $25 million in this fiscal year. (3) North Carolina, in order to take a comprehensive long term approach to the cost and quality of the NC Medicaid program, has developed Community Care of NC, voluntary regional provider networks, that implement local quality and cost containment initiatives. To date, there are 13 networks involving more than 3,000 physicians and other healthcare providers covering 543,574 Medicaid recipients. In addition to providing patients a medical home and implementing disease management initiatives such as asthma and diabetes, these networks address high cost patients, and implement utilization programs. The development of this local infrastructure provide lasting system change and move toward a more comprehensive monitoring of total cost and quality of care for specific patients with specific diseases in the NC Medicaid program. A recent evaluation by Mercer Consulting Group indicates that CCNC is saving an additional $60 million dollars a year by preventing hospitalizations and better use of resources.(4) It is our belief that evidenced based and targeted policy decisions and the full development of our community-based delivery systems will allow NC to provide high quality health care to our states poorest citizens at the lowest possible cost. 1- Fink KS, Byrns PJ. Changing prescribing patterns and increasing prescription expenditures in Medicaid. Ann Fam Med 2004; 2:488-93. 2- Program Expenditure Report FYE 2004, NCDHHS 3- Henley N, Dobson A. Outpatient Pharmacy Program: report to the Blue Ribbon Commission on Medicaid Reform, NC General Assembly Oct 6, 2004 4-Torlen Wade, NCDHHS Oct 8, 2004 Competing interests: Dr Dobson is Chairman of the NC Physicians Advisory Group that advises NC Medicaid on Health Policy |
|||
|
|
|||
|
S. Troy McMullin, Bend, Oregon USA Clinical Decision Support, WELLINX Inc
Send response to journal:
|
We found the study by Drs. Fink and Byrns particularly interesting, as our own research has yielded similar conclusions regarding the need for evidence-based, fiscally responsible prescribing.(1,2) Despite collecting data in different patient populations and in different years, there were remarkable similarities in these two reports--especially within the list of high-cost medications. Importantly, subsequent analyses of our data have identified significant declines in the use of many of the medications that contributed to the rising prescription expenditures in the North Carolina Medicaid program (e.g., proton pump inhibitors, nonsedating antihistamines, single-source selective serotonin reuptake inhibitors, COX -2 inhibitors, and calcium channel blockers). Although computerized decision support systems (CDSS), such as the one we describe, can be used to improve appropriate and cost-effective prescribing, medical groups have not rapidly adopted these tools. The two primary obstacles that prevent medical groups from investing in CDSS have been the cost of the systems and the lack of direct financial benefit to their physicians. Other than the indirect benefits of reduced phone calls to verify prescription information and decreased time to process prescription renewals, most financial savings associated with the use of CDSS accrue to insurers, employers, and patients rather than to individual physicians. We believe more physicians would adopt CDSS and embrace evidence- based prescribing if government- or payer-sponsored incentives were in place that helped medical groups offset the cost of CDSS, and rewarded them for investing in the infrastructure necessary to improve prescribing. We are hopeful that the recent interest in pay for performance programs will better align payer and physician interests, and lead to sustained improvements in prescribing patterns and patient care. (1.) Fink KS, Byrns PJ. Changing prescribing patterns and increasing prescription expenditures in Medicaid. Ann Fam Med 2004; 2:488-93. (2.) McMullin ST, Lonergan TL, Rynearson CA, et al. Impact of an evidence-based computerized decision support system on primary care prescription costs. Ann Fam Med 2004; 2:494-8. Competing interests: Dr. McMullin is employed by WELLINX, a company that markets an electronic prescribing system with integrated evidence-based decision support |
|||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
TRACK: