stephen soumerai, sc.d. professor department of ambulatory care and prevention harvard medical...
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Stephen Soumerai, Sc.DStephen Soumerai, Sc.D..ProfessorProfessor
Department of Ambulatory Care Department of Ambulatory Care and Preventionand Prevention
Harvard Medical School and Harvard Medical School and Harvard Pilgrim Health CareHarvard Pilgrim Health Care
Designing Pharmacy Benefits to Improve Quality and
Contain Costs
Evolution of Prescription Drug Evolution of Prescription Drug Benefits DesignsBenefits Designs
Non-selective “blunt” tools can have Non-selective “blunt” tools can have unintended consequences, reduce clinical unintended consequences, reduce clinical effectiveness, and increase total costseffectiveness, and increase total costs Caps on number of prescriptionsCaps on number of prescriptions Non-selective cost sharingNon-selective cost sharing Triplicate prescriptions Triplicate prescriptions
Evolution of Prescription Drug Evolution of Prescription Drug Benefits Designs (cont’d)Benefits Designs (cont’d)
Initial studies suggest that selective Initial studies suggest that selective “sharp” tools that recognize relative “sharp” tools that recognize relative effectiveness of drugs within a class can effectiveness of drugs within a class can reduce inappropriate use and promote reduce inappropriate use and promote least-costly alternativesleast-costly alternatives Reference pricingReference pricing Tiered copaymentsTiered copayments Evidence-based preferred drug lists and Evidence-based preferred drug lists and
formularies formularies
Unintended effects of non-Unintended effects of non-selective cost-sharing policies selective cost-sharing policies
Reduces use of clinically important Reduces use of clinically important medicines (e.g., insulin, cardiac meds)medicines (e.g., insulin, cardiac meds)
Increases use of institutional servicesIncreases use of institutional services– Nursing homes and hospitals (elderly)Nursing homes and hospitals (elderly)– Day hospital and acute care (patients with Day hospital and acute care (patients with
schizophrenia.)schizophrenia.)
May increase total health care costsMay increase total health care costs– Mental health cost offsets 17 x drug savingsMental health cost offsets 17 x drug savings
Time Series of Constant-Size Rxs per Time Series of Constant-Size Rxs per Continuously Eligible Patient per Month among Continuously Eligible Patient per Month among
Multiple Drug Recipients (N=860) and Other Multiple Drug Recipients (N=860) and Other Outpatients (N=8002)Outpatients (N=8002)
Source: Soumerai et al, N Engl J Med 1987; 317: 550-6
Cap-induced Changes in Essential Drugs: Cap-induced Changes in Essential Drugs: “Droppers” vs. “Maintainers”“Droppers” vs. “Maintainers”
0
1
2
3
4
ST
AN
DA
RD
DO
SE
S P
ER
EL
IGIB
LE
PE
RS
ON
BASELINE 3 DRUG CAP $1 COPAY
JUL ‘81 JUL ‘82JUL ‘80
DOSES REDUCED
DOSES MAINTAINED
Source: Soumerai et al, N Engl J Med 1994; 331: 650-5
Effects of Prescription Cap on Effects of Prescription Cap on Nursing Home AdmissionsNursing Home Admissions
80%
85%
90%
95%
100%
Baseline Cap After Cap
% o
uts
ide
nu
rsin
g h
om
e
New Jersey
New Hampshire
Source: Soumerai et al, N Engl J Med 1991; 325: 1072-7
Effect of Cap on Emergency Mental Effect of Cap on Emergency Mental Health ServicesHealth Services
-0.1
0
0.1
0.2
0.3
0.4
0.5
6 12 18 24 30 36 42
Month
No
. o
f S
erv
ice
s p
er
Pt. CMHC 1 CMHC 2
Baseline Cap After Cap
Source: Soumerai et al, N Engl J Med 1994; 331: 650-5
0.0
0.7
1.4
2.1
No. o
f dru
gs p
er d
ay
.
Observed
Predicted (--- 95% CI)
11-93 8-94 8-95 8-96 8-97
Elderly (n=70801)
Policy
Adult Welfare (n=25820)
11-93 8-94 8-95 8-96 8-97
Policy Initiated
Changes in Use of Essential Drugs Changes in Use of Essential Drugs With Change in Cost SharingWith Change in Cost Sharing
Source: Tamblyn R et al, JAMA 2001; 285: 421-429
Effect of a $0.50 per Rx Copayment on Medication Use by Medicaid Recipients in
South Carolina
Source: Nelson, Reeder & Dickson. Med Care Aug. 1984 p. 724
Number of BZ Recipients Per Month
0.0
2.0
4.0
6.0
8.0
10.0
Jan-88 Jul-88 Jan-89 Jul-89 Jan-90 Jul-90
BZ
Re
cip
ien
ts P
er
10
0
Co
nti
nu
ou
s E
nro
llee
sImpact of Triplicate Prescription Program Impact of Triplicate Prescription Program
(TPP) on Benzodiazepine (BZ) (TPP) on Benzodiazepine (BZ) PrescribingPrescribing
New Jersey
New York(-54.8%)
Triplicate Policy
Source: Ross-Degnan et al (submitted)
Impact of TPP on Use of BZ Indicated Impact of TPP on Use of BZ Indicated for Seizure and Panic Disorderfor Seizure and Panic Disorder
Clonazepam
0.0%
0.2%
0.4%
0.6%
01/88 01/89 01/90
% o
f E
nro
lle
es Triplicate Policy
New Jersey
New York
Source: Ross-Degnan et al (submitted)
Reduction in BZ Use Among Patients with Seizure Disorder
0
2
4
6
8
10
12
14
16
Jan-88 Jul-88 Jan-89 Jul-89 Jan-90 Jul-90
Per
cen
t o
f P
atie
nts
wit
h B
Z U
se
TPP Policy
NY Study Cohort
NJ Control Cohort
Source: Simoni-Wastila et al (submitted)