In the elderly (those aged ≥65 years), retail pharmacy claims are used to study drug use among the uninsured after drug policy changes, to prevent drug drug interactions and duplication of therapy, and to guide medication therapy management. Claims include only prescriptions filled at one pharmacy location or within one pharmacy chain and do not include prescriptions filled at outside pharmacies, potentially limiting research accuracy and pharmacy-based safety interventions.
The aims of this study were to assess elderly patients’ pharmacy loyalty and to identify predictors of using multiple pharmacies.
Patients enrolled in the Pharmaceutical Assistance Contract for the Elderly pharmacy benefit program with corresponding Medicare claims in the state of Pennsylvania comprised the study cohort. Among patients with pharmacy claims from all pharmacies used in 2004–2005, a primary pharmacy was defined as the pharmacy where >50% of a patient’s prescriptions were filled. The number of pharmacies/chains used and prescriptions filled in 2005 was calculated. Predictors of using multiple pharmacies in 2005 were age, gender, race, urban residency, comorbidities, number of unique medications used, and number of prescriptions, which were all assessed in 2004.
In total, pharmacy claims data from 182,235 patients (147,718 [81.1%] women; mean [SD] age 78.8 [7.1] years; 168,175 white; 76,580 residing in an urban zip code area) were included. In 2005, patients filled an average of 59.3 prescriptions, with 57.0 (96.1%) prescriptions having been filled at the primary pharmacy. Compared with patients who used <5 unique medications in 2004, patients who used 6 to 9 unique medications had 1.39 times (95% CI, 1.34–1.44), and patients who used 15 unique medications had 2.68 times (95% CI, 2.55–2.82) greater likelihood of using multiple pharmacies in 2005. Patients aged ≥85 years were 1.07 times (95% CI, 1.03–1.11) as likely to use multiple pharmacies compared with patients aged 65 to 74 years.
This study found that patients aged ≥65 years were loyal to their primary pharmacy, offering reassurance to researchers and pharmacists who use retail pharmacy claims to evaluate and/or to improve safe and appropriate medication use among the elderly. Care should be used in analyzing claims from or managing the drug regimens of patients using many medications or patients aged ≥85 years; they are more likely to use multiple pharmacies and thus are more likely to have missing prescription information.
retail pharmacy; medication errors; drug utilization; loyalty; missing data
To estimate the impact of a soft cap (a ceiling on utilization beyond which insured enrollees pay a higher copayment) on low-income elders' use of prescription drugs.
Data Sources and Setting
Claims and enrollment files for the first year (June 2002 through May 2003) of the Illinois SeniorCare program, a state pharmacy assistance program, and Medicare claims and enrollment files, 2001 through 2003. SeniorCare enrolled non-Medicaid-eligible elders with income less than 200 percent of Federal Poverty Level. Minimal copays increased by 20 percent of prescription cost when enrollee expenditures reached $1,750.
Models were estimated for three dependent variables: enrollees' average monthly utilization (number of prescriptions), spending, and the proportion of drugs that were generic rather than brand. Observations included all program enrollees who exceeded the cap and covered two periods, before and after the cap was exceeded.
On average, enrollees exceeding the cap reduced the number of drugs they purchased by 14 percent, monthly expenditures decreased by 19 percent, and the proportion generic increased by 4 percent, all significant at p<.01. Impacts were greater for enrollees with greater initial spending, for enrollees without one of five chronic illness diagnoses in the previous calendar year, and for enrollees with lower income.
Near-poor elders enrolled in plans with caps or coverage gaps, including Part D plans, may face sharp declines in utilization when they exceed these thresholds.
Prescription drugs; copayments; elasticity of demand; low-income elderly
Dose escalation with tumor necrosis factor (TNF)-blockers is poorly characterized in pharmacy benefit management (PBM) settings.
This retrospective study used integrated pharmacy and medical claims from the PBM Medco to characterize dose escalation among rheumatoid arthritis (RA) patients treated with etanercept and adalimumab. Data from adults with RA with pharmacy claims for etanercept or adalimumab between 1/1/2007 and 12/31/2009 and continuous enrollment for ≥6 months before and ≥12 months after first (index) pharmacy claim were analyzed. “New” patients had no claim for TNF-blocker in the 6 months prior to receipt of their index TNF-blocker; otherwise, they were classified as “continuing” patients. Endpoints included 12-month persistence and duration on index medication and dose escalation. Dose escalation (allowed per adalimumab label but not for etanercept) in patients’ persistent ≥12 months was estimated using five methods: (1) average weekly dose ≥110% of recommended label dose; (2) average subsequent dose ≥130% of starting dose; (3) last dose ≥110% of starting dose; (4) ≥2 consecutive instances of dose ≥130% of starting dose; and (5) any instance where dose increase connoted an additional syringe/vial use.
Data from 1,260 patients on etanercept and 852 patients on adalimumab were analyzed; 45.3 and 45.9% of new patients on etanercept and adalimumab, respectively, and 60.5 and 60.8% of continuing patients had ≥12 months persistence on index medication. Across all five methods used to estimate dose escalation, patients receiving etanercept had significantly lower rates of dose escalation (P < 0.001) than patients receiving adalimumab. For new patients, rates of dose escalation were 0.4–1.2% for etanercept and 8.3–14.1% for adalimumab. For continuing patients, rates ranged from 1.1 to 2.9% for etanercept and 7.0–28.3% for adalimumab.
New and continuing patients from this PBM database on etanercept had significantly lower rates of dose escalation than patients on adalimumab.
Adalimumab; Dose escalation; Etanercept; Pharmacy benefit management; Rheumatoid arthritis
Antibiotic prophylaxis (AP) is commonly used for medical management of vesicoureteral reflux (VUR). Little information exists on AP compliance in VUR patients.
Materials and Methods
We queried the Innovus i3 pharmacy claims 2002–2007 database for children ≤18yrs with VUR (ICD-9 code 593.7, plus claim for cystogram) and analyzed those with at least 1yr of follow-up data. Criteria for management with AP were ≥two 30-day supply antibiotic prescriptions or ≥four 14-day supply prescriptions if the antibiotic was a penicillin or cephalosporin. AP compliance was determined using a medication possession ratio, an estimate of the proportion of time that patients have a prescribed drug available for use. Compliance was established as a medication possession ratio of ≥80%, meaning coverage with AP for ≥80% of the year.
5,342 out of 9,496 VUR patients (56.3%) were managed on AP. Most patients were female (81%) and ≤5yrs old (79%). Trimethoprims/sulfonamides were most commonly prescribed (62%); antiseptics were next (24%). 40% of patients on AP were compliant. Compliance was lower for 6–10yr olds (OR .71, 95CI 0.61–0.83) and 11–18yr olds (OR 0.56, 95CI 0.41–0.79) compared to younger children (≤5yrs). Increased compliance was associated with ≥1 hospitalizations (OR 1.70, 95CI 1.48–1.97) and ≥1 urologist visits (OR 1.41, 95CI 1.25–1.58).
40% of VUR patients on AP are compliant, with young age, frequent hospitalization, and specialist visits associated with compliance. This knowledge may help to develop effective interventions to improve compliance and underscores the importance of reporting compliance in clinical studies evaluating the utility of AP in VUR management.
vesicoureteral reflux; antibiotics; prophylaxis; compliance; outcome
To examine whether high-deductible health plans (HDHPs) that exempt prescription drugs from full cost sharing preserve medication use for major chronic illness, compared with traditional HMOs with similar drug cost sharing.
Data Sources/Study Setting
We examined 2001–2008 pharmacy claims data of 3,348 continuously enrolled adults in a Massachusetts health plan for 9 months before and 24 months after an employer-mandated switch from a traditional HMO plan to a HDHP, compared with 20,534 contemporaneous matched HMO members. Both study groups faced similar three-tiered drug copayments. We calculated daily medication availability for all prescription drugs and four chronic medication classes: hypoglycemics, lipid-lowering agents, antihypertensives, and chronic obstructive pulmonary disease (COPD)/asthma controllers.
Interrupted time-series with comparison group study design examining monthly level and trend changes in prescription drug utilization.
The HDHP and control groups had comparable changes in the level and trend of all drugs after the index date; we detected similar patterns in the use of lipid-lowering agents, antihypertensives, and COPD/asthma controllers. Some evidence suggested a small relative decline in hypoglycemic use among diabetic patients in HDHPs.
Switching to an HDHP that included modest drug copayments did not change medication availability or reduce use of essential medications for three common chronic illnesses.
High-deductible health plans; pharmaceutical use; chronic disease; differential cost-sharing
To evaluate the impact of managed care on the use of chronic disease medications.
Claims data from 1997 from two indemnity and three independent practice association (IPA) model managed care insurance plans.
Cross-sectional analysis of claims data.
Adult patients with diabetes mellitus (DM, n=26,444), congestive heart failure (CHF, n=7,978), and asthma (n=9,850) were identified by ICD-9 codes. Chronic disease medication use was defined through pharmacy claims for patients receiving one or more prescriptions for drugs used in treating these conditions. Using multiple logistic regression we adjusted for patient case mix and the number of primary care visits.
With few exceptions, managed care patients were more likely to use chronic disease medications than indemnity patients. In DM, managed care patients were more likely to use sulfonylureas (43 percent versus 39 percent for indemnity), metformin (26 percent versus 18 percent), and troglitazone (8.8 percent versus 6.4 percent), but not insulin. For CHF patients, managed care patients were more likely to use loop diuretics (45 percent versus 41 percent), ACE inhibitors or angiotensin receptor blockers (50 percent versus 41 percent), and beta-blockers (23 percent versus 16 percent), but we found no differences in digoxin use. In asthma, managed care patients were more likely to use inhaled corticosteroids (34 percent versus 30 percent), systemic corticosteroids (18 percent versus 16 percent), short-acting beta-agonists (42 percent versus 33 percent), long-acting beta-agonists (9.9 percent versus 8.6 percent), and leukotriene modifiers (5.4 percent versus 4.1 percent), but not cromolyn or methylxanthines. Statistically significant differences remained after multivariate analysis that controlled for age, gender, and severity.
Chronic disease patients in these managed care plans are more likely to receive both inexpensive and expensive medications. Exceptions included older medications partly supplanted by newer therapies. Differences may be explained by the fact that patients in indemnity plans face higher out-of-pocket costs and managed care plans promote more aggressive medication use. The relatively low likelihood of condition-specific medications in both plan types is a matter of concern, however.
Managed care; physician; practice patterns; medication prescribing; chronic disease
Electronic Prescribing (ePrescribing) is the process of prescribing medications using an outpatient computerized physician order entry (CPOE) system that electronically exchanges prescriptions directly with the pharmacy and/or pharmacy benefits manager (PBM). Our project aims to evaluate proposed ePrescription transmission standards and a community utility for ePrescribing called the eRx Gateway for safety, quality and efficiency.
OBJECTIVE: To model the bargaining power of pharmacies and insurers in price negotiations and test whether it varies with characteristics of the pharmacy, insurer, and pharmacy market. DATA SOURCES/STUDY SETTING: Data from four sources. Pharmacy/insurer transactions were taken from Medstat's universe of 6.8 million pharmacy claims in their 1994 Marketscan database. Sources Informatics, Inc. supplied a three-digit zip code-level summary database containing pharmacy payments and self-reported costs for retail (cash-paying) customers for the top 200 pharmaceutical products by prescription size in 1994. The National Council of Prescription Drug Programs supplied their 1994 pharmacy database. Zip code-level socioeconomic and commercial information was taken from Bureau of the Census' 1990 Summary Tape File 3B and 1994 Zip Code Business Patterns database. STUDY DESIGN: The provider/insurer bargaining model first employed in Brooks, Dor, and Wong (1997, 1998) was adapted to the circumstances surrounding pharmacy and insurer bargaining. DATA COLLECTION/EXTRACTION METHODS: The units of observation in this study were single Medstat claims for each unique insurer/pharmacy combination in the database for selected pharmaceutical products. The four products selected varied in the conditions they treat, whether they are used to treat chronic or acute conditions, and by their sales volume. Used in the analysis were 9,758 Zantac, 2,681 Humulin, 3,437 Mevacor, and 1,860 Dilantin observations. PRINCIPAL FINDINGS: We find statistically significant variation in pharmacy bargaining power. Pharmacy bargaining power varies significantly across markets, insurers, and pharmacy types. With respect to market structure, pharmacy bargaining power is negatively related to pharmacies per capita and pharmacies per employer and positively related to pharmacy concentration at higher concentration levels. In addition, the higher the percentage of independent pharmacies in an area, the lower the pharmacy bargaining power. With respect to socioeconomic conditions, pharmacy bargaining power is higher in areas with lower per capita income and higher rates of public assistance. CONCLUSIONS: The bargaining power of pharmacies in contract negotiations with insurers varies considerably with exogenous factors. Local area pharmacy ownership concentration enhances pharmacy bargaining. As a result, anti-trust law prohibiting the collective bargaining of independent pharmacies with insurers leaves independents at a disadvantage with respect to chains.
OBJECTIVE: To identify the population-based drug databases in Canada and to determine their comprehensiveness and accessibility for performing pharmacoepidemiologic and outcomes research. DESIGN: Survey (four-part mailed questionnaire). SETTING: Public and private third-party drug plans across Canada. PARTICIPANTS: All provincial and territorial drug plan or pharmacare managers as well as selected private plan managers including health benefit consultants, group insurers and claims adjudicators/pharmacy benefit managers (CA/PBMs). OUTCOME MEASURES: Patient, drug and pharmacy information; potential for electronic linkages to other provincial databases (e.g., physician, hospital, vital statistics); accessibility of information; population profile. RESULTS: Of the 32 recipients of the questionnaire 29 (91%) responded and 18 (56%) completed the survey. Most databases were reported to contain patient information (e.g., patient identification number, age, sex and medication history) and prescription drug information (e.g., drug identification number, strength, quantity and cost). Six provinces and one territory reported the capability to link to other databases (e.g., hospital and physician databases). One CA/PBM reported some links to selected long-term disability data. All of the government databases except those in British Columbia and the Yukon Territory allowed use of the data for research purposes. Manitoba and Saskatchewan included all residents of the province in their database; the others included selected groups (e.g., residents 65 years of age or older, people on social assistance or people covered by private group insurance). CONCLUSION: A number of public and private population-based databases are available for use in pharmacoepidemiologic and outcomes research.
Prescription opioid abuse and addiction are serious problems with growing societal and medical costs, resulting in billions of dollars of excess costs to private and governmental health insurers annually. Though difficult to accurately assess, prescription opioid abuse also leads to increased insurance costs in the form of property and liability claims, and costs to state and local governments for judicial, emergency, and social services. This manuscript’s objective is to provide payers with strategies to control these costs, while supporting safe use of prescription opioid medications for patients with chronic pain.
A Tufts Health Care Institute Program on Opioid Risk Management meeting was convened in June 2010 with private and public payer representatives, public health and law enforcement officials, pain specialists, and other stakeholders to present research, and develop recommendations on solutions that payers might implement to combat this problem.
While protecting access to prescription opioids for patients with pain, private and public payers can implement strategies to mitigate financial risks associated with opioid abuse, using internal strategies, such as formulary controls, claims data surveillance, and claims matching; and external policies and procedures that support and educate physicians on reducing opioid risks among patients with chronic pain.
Reimbursement policies, incentives, and health technology systems that encourage physicians to use universal precautions, to consult prescription monitoring program (PMP) data, and to implement Screening, Brief Intervention, and Referral to6Treatment protocols, have a high potential to reduce insurer risks while addressing a serious public health problem.
opioid abuse; opioid addiction; substance abuse; reimbursement; payer
To assess health care disparities among black and Latino adults with schizophrenia receiving services during the period July 1994–June 2006, and to evaluate trends in observed disparities.
Administrative claims data from the Florida Medicaid program. Data sources included membership files (demographic information), medical claims (diagnostic, service, and expenditure information), and pharmacy claims (prescriptions used and expenditures).
We identified adults with at least two schizophrenia claims during a fiscal year. We used generalized estimating equation models to estimate disparities in spending on psychotropic drugs, psychiatric inpatient services, all mental health services, and all health services.
Spending on psychotropic drugs, mental health, and all health was 0.9–70 percent lower for blacks and Latinos than for whites. With the exception of blacks with substance use disorder comorbidity, minorities were less likely than whites to use psychiatric inpatient services. Psychiatric inpatient spending among users did not differ by race/ethnicity. With the exception of psychiatric inpatient utilization/spending, trend analyses showed no change or modest reductions in disparities.
Black and Latino Medicaid recipients diagnosed with schizophrenia experience health care disparities. Some but not all disparities narrowed modestly over the study period.
Racial/ethnic disparities; schizophrenia; quality of care; trends; Medicaid
Clinicians often encounter information about drug-drug interactions (DDIs) during clinical practice. This information is found within product information (hardcopy and electronic) and various electronic systems. Prescribers may receive medication-related communications in practice that are distributed by facsimile (fax), mail, or telephone from pharmacies and pharmacy benefit managers (PBMs). The purpose of this study was to determine if near-real time fax alerts for potential drug-drug interactions (PDDIs) would influence prescribing.
A prospective study, in cooperation with a pharmacy benefit manager (PBM), was conducted targeting 18 clinically important PDDIs. Fax alerts included an individualized letter to the prescriber with a list of the interacting drugs, PDDI evidence summaries with citations, and recommended clinical management strategies. Among the 18 PDDIs, 13 PDDIs could be assessed for prescription therapy changes using pharmacy claims data. A prospective cohort design was used to evaluate changes in prescription dispensing 90-days following a PDDI fax alert.
A total of 8,075 fax alerts were sent to prescribers and there were 4,712 alerts for the 13 PDDIs that could be assessed for change using pharmacy claims data. There were 2,019 patients (interventions) for which fax alerts were sent to their prescribers who were matched with a control group consisting of patients with the same PDDIs but for whom no fax alert was sent. Overall, this study found 154 (7.6%) of patients in the fax alert group compared to 132 (6.5%) in the control group had changes in therapy (p = 0.177).
This fax alert intervention program observed no statistically significant differences in prescribing with a fax alert compared to the control group. If PBMs chose to send individualized, evidence-based information to clinicians regarding drug-drug interactions, this study suggests it may not be an effective intervention to mitigate harm.
Drug interactions; Drug safety; Physician; Prescriber; Fax
Insurers and policymakers strive to stimulate more cost-effective prescribing and, increasingly, are educating beneficiaries about generics.
To evaluate the relationship between patient beliefs and communication about generic drugs and actual drug use.
Research Design and Subjects
We performed a national mailed survey of a random sample of 2500 commercially-insured adults. Patient responses were linked to pharmacy claims data to assess actual generic medication use.
We used factor analysis to develop 5 multi-item scales from patient survey responses that measured: (1) general preferences for generics, (2) generic safety/effectiveness, (3) generic cost/value, (4) comfort with generic substitution, and (5) communication with providers about generics. The relationship between each scale and the proportion of prescriptions filled for generics was assessed using linear regression, controlling for demographic, health, and insurance characteristics. Separate models were created for each scale and then all 5 scales were included simultaneously in a fully-adjusted model.
The usable response rate was 48%. When evaluated independently, a 1 SD increase in each of the 5 scales was associated with a 3.1% to 6.3% increase in generic drug use (P < 0.05 for each). In the fully adjusted model, only 2 scales were significantly associated with generic drug use: comfort with generic substitution (P = 0.021) and communication with providers about generic drugs (P = 0.012).
Generic drug use is most closely associated with the 2 actionable items we evaluated: communication with providers about generics and comfort with generic substitution. Educational campaigns that focus on these 2 domains may be most effective at influencing generic drug use.
generic; medications; utilization; perceptions; communication
The true treatment rate for hepatitis C virus (HCV) in veterans is unknown.
To determine the treatment prescription rates and predictors of treatment prescription for HCV in a large national population.
The Department of Veterans Affairs National Patient Care Database (NPCD) was used to identify all HCV‐infected people between the fiscal years 1999 and 2003 using the International classification of diseases, 9th revision codes. Demographic information, medical and psychiatric comorbidities, and drug and alcohol use diagnoses were retrieved. Pharmacy data were retrieved from the Department of Veterans Affairs Pharmacy Benefits Management (PBM) database. Logistic regression analysis was used to determine the predictors of treatment for HCV in HCV.
113 927 veterans in the Department of Veterans Affairs care with a diagnosis of HCV were identified. The treatment prescription rate for HCV was 11.8%. Patients not prescribed treatment were older, more likely to be from minority races, have more alcohol and drug misuse, and have medical and psychiatric comorbid conditions. In a multivariate logistic regression model, the following factors were predictive of non‐treatment for HCV: increasing age (odds ratio (OR) 0.77 for each 5‐year increase in age; 95% confidence interval (CI) 0.76 to 0.78); black race (OR 0.64; 95% CI 0.6 to 0.68); Hispanic race (OR 0.88; 95% CI 0.8 to 0.96); alcohol abuse and dependence (OR 0.62; 95% CI 0.59 to 0.65); drug abuse and dependence (OR 0.78; 95% CI 0.74 to 0.82); anaemia (OR 0.18; 95% CI 0.16 to 0.21); hepatitis B infection (OR 0.72; 95% CI 0.62 to 0.83); coronary artery disease (OR 0.9; 95% CI 0.85 to 0.97); stroke (OR 0.75; 95% CI 0.67 to 0.85); bipolar disorder (OR 0.64; 95% CI 0.58 to 0.70); major depression (OR 0.72; 95% CI 0.67 to 0.77); mild depression (OR 0.56; 95% CI 0.53 to 0.59); and schizophrenia (OR 0.71; 95% CI 0.65 to 0.77). The following factors were associated with a higher likelihood of treatment prescription for HCV: liver cirrhosis (OR 1.6; 95% CI 1.5 to 1.7); and diabetes (OR 1.07; 95% CI 1.02 to 1.12).
A small number of HCV‐infected veterans were prescribed treatment for HCV. Non‐treatment is associated with increasing age, non‐white race, drug and alcohol abuse, and dependence and comorbid illnesses. Reasons for non‐treatment need further study.
Disclosure of medical research results to the public creates tension between lay medical reporters and the medical profession.
To explore the early effect of media attention on the risks associated with short-acting calcium channel blockers (CCBs) for treating hypertension after publication at a national meeting and following publication.
Time-series analysis of prescription claims data.
SETTING AND DATA SOURCE
National third-party pharmaceutical benefits manager.
Employed or retired persons and their families, 18 years of age or older, receiving prescription benefits from 1 of 4 national companies that contracted with the pharmaceutical benefits manager exclusively for prescription drug coverage.
Prescription claims for antihypertensive drugs by fill date converted to a percentage of all cardiovascular drug claims. Data were grouped into weekly intervals before and immediately after the national release of negative information about CCBs on March 10, 1995 and following publication of the results on August 23, 1995.
The most prevalent antihypertensive drugs were diuretics (21% of cardiovascular prescription claims) and calcium channel blockers (19%). A 10% decline in prescriptions filled for CCBs occurred 4 weeks following the intense media attention. Only prescriptions for long-acting calcium channel blockers declined. Alpha-1-blocker prescriptions increased by approximately the same amount that prescriptions for CCBs declined, suggesting substitution of one drug for the other. Changes in diuretic or β-blocker prescriptions filled were not statistically significant. No immediate change in other cardiovascular drug classes occurred following journal publication.
Intense media publicity regarding a controversial study measurably and unpredictably changed prescription claims.
media; communication; hypertension; calcium channel blockers
To study the impact of various elements of pharmacy benefit design on both the absolute and relative utilization of generics, brands, retail pharmacy, and mail service.
Panel data on 1,074 plan sponsors covering 21.6 million individuals over 12 calendar quarters (2005–2007).
A retrospective analysis of pharmacy claims.
To control for potential endogeneity, linear fixed effects models were estimated for each of six dependent variables: the generic utilization rate, the brand utilization rate, the generic dispensing rate (GDR), the retail pharmacy utilization rate, the mail service utilization rate, and the mail distribution rate.
Most member cost-share variables were nonlinearly associated with changes in prescription drug utilization. Marginal effects were generally greater in magnitude for brand out-of-pocket costs than for generic out-of-pocket costs. Time dummies, as well as other pharmacy benefit design elements, also yielded significant results.
Prior estimates of the effect of member cost sharing on prescription drug utilization may be biased if complex benefit designs, mail service fulfillment, and unmeasured factors such as pharmaceutical pipelines are not accounted for. Commonly cited relative utilization metrics, such as GDR, may be misleading if not examined alongside absolute prescription drug utilization.
Pharmacy benefit design; cost sharing; generic dispensing; mail service utilization
Increased use of generic medications conserves insurer and patient financial resources and may increase patient adherence.
The objective of the study is to evaluate whether physician, patient, pharmacy benefit design, or pharmacy characteristics influence the likelihood that patients will use generic drugs
DESIGN, SETTING, AND PARTICIPANTS
Observational analysis of 2001–2003 pharmacy claims from a large health plan in the Western United States. We evaluated claims for 5,399 patients who filled a new prescription in at least 1 of 5 classes of chronic medications with generic alternatives. We identified patients initiated on generic drugs and those started on branded medications who switched to generic drugs in the subsequent year. We used generalized estimating equations to perform separate analyses assessing the relationship between independent variables and the probability that patients were initiated on or switched to generic drugs.
Of the 5,399 new prescriptions filled, 1,262 (23.4%) were generics. Of those initiated on branded medications, 606 (14.9%) switched to a generic drug in the same class in the subsequent year. After regression adjustment, patients residing in high-income zip codes were more likely to initiate treatment with a generic than patients in low-income regions (RR = 1.29; 95% C.I. 1.04–1.60); medical subspecialists (RR = 0.82; 0.69–0.95) and obstetrician/gynecologists (RR = 0.81; 0.69–0.98) were less likely than generalist physicians to initiate generics. Pharmacy benefit design and pharmacy type were not associated with initiation of generic medications. However, patients were over 2.5 times more likely to switch from branded to generic medications if they were enrolled in 3-tier pharmacy plans (95% C.I. 1.12–6.09), and patients who used mail-order pharmacies were 60% more likely to switch to a generic (95% C.I. 1.18–2.30) after initiating treatment with a branded drug.
Physician and patient factors have an important influence on generic drug initiation, with the patients who live in the poorest zip codes paradoxically receiving generic drugs least often. While tiered pharmacy benefit designs and mail-order pharmacies helped steer patients towards generic medications once the first prescription has been filled, they had little effect on initial prescriptions. Providing patients and physicians with information about generic alternatives may reduce costs and lead to more equitable care.
patient; physician; pharmacy; pharmacy benefit; design; generic medications; medication costs
To compare physician-reported adherence of specific patients to oral second-generation antipsychotics vs. actual adherence rates determined from the patients’ pharmacy claims.
Claims data from the HealthCore Integrated Research Database identified patients with schizophrenia or bipolar disorder with ≥1 oral second-generation antipsychotic prescription. The prescribing physicians were identified from the pharmacy claims and asked to complete an Internet survey assessing their perception of medication adherence for 1–2 of their patients and their beliefs regarding adherence to second-generation antipsychotics in general for a 1-year period. Adherence to second-generation antipsychotics was determined for each patient by pharmacy claims for the same period. Physician survey data were merged with patient claims data via unique patient identifiers, and physician-reported adherence rates were compared with claims-based rates as measured by the medication possession ratio.
One hundred and fifty-three physicians responded to the survey, representing 214 patients (44 with claims for schizophrenia, 162 with bipolar disorder, 8 with claims for bipolar disorder and schizophrenia). Most physicians (60%) had no formal adherence training. More than two-thirds (68%) reported emphasising the importance of adherence and reported approximately 76% of their patients were adherent (≥71% of the time). In the schizophrenia group, 16 of 17 (94%) patients with low-to-moderate (≤70%) adherence levels had high (≥71%) physician-estimated adherence. In the bipolar disorder group, 62 of 92 (67%) patients with low-to-moderate adherence levels had high physician-estimated adherence.
These analyses suggest that, even when physicians are asked about specific patients in their practice, there is discordance between physician perceptions and adherence as measured through pharmacy claims. This disparity may delay appropriate interventions, potentially contributing to relapses.
The price per milligram for most statin medications decreases at higher strengths, which provides an economic incentive to split tablets. We sought to determine the frequency with which statin tablets are split, and to evaluate factors associated with this practice.
We obtained prescription claims data for statins from the BC Ministry of Health for the period Jan. 1, 1996, to Dec. 31, 2006. We estimated the number of tablets per day, based on the ratio of the number of tablets to days-supply in each prescription, to estimate the frequency with which splitting occurred with each statin. We used multivariable logistic regression to assess patient and physician characteristics and the level of public drug plan coverage associated with tablet splitting. To estimate related cost savings, we used information on drug costs and quantities of dispensed statins reported by pharmacies.
During the 11-year study period, we estimated that tablet splitting occurred in 2.6% of 7.2 million statin prescriptions. There was an increasing trend in the practice over time, to 4.5% of prescriptions in 2006. Lovastatin was the only scored tablet and was the most likely to be split, followed by rosuvastatin and atorvastatin. Fifty percent of the prescriptions in which tablet splitting occurred were prescribed by only 7.9% of the routine statin prescribers (i.e., > 10 statin prescriptions over the study period). Specialists were less likely than general practitioners to prescribe statins that were subsequently split (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.40–0.46). Statin prescriptions that were fully covered by the public drug plan were half as likely as those with no such coverage to involve tablet splitting (OR 0.48, 95% CI 0.44–0.92). Having no public drug coverage, having a low annual household income and being female were patient factors found to be positively associated with tablet splitting. In 2006, the cost savings associated with tablet splitting was $2.3 million.
The frequency of tablet splitting in statin prescriptions in British Columbia was low but increased over time. It varied between patients, physicians and different levels of insurance coverage. In the final study year, 94.5% of the statin prescriptions were dispensed at strengths for which a tablet of twice the strength was available and could have been split, which suggests a potentially enormous cost savings.
Prescription drug spending and pharmacy benefit design have changed substantially over the last decade, yet little is known about the financial impact these changes have had on consumers. We examined ten years of nationally representative data from the Medical Expenditure Panel Survey and describe trends in two measures of financial burden for prescription drugs: out-of-pocket drug costs as a function of family income and the proportion of all out-of-pocket health care costs accounted for by drugs. We found that although the percentage of people with high financial burden for prescription drugs increased from 1999 to 2003, it decreased from 2003 to 2007, with a slight increase in 2008. The decline is evidence of the success of strategies to lower drug costs for consumers, including the increased use of generic drugs. However, the financial burden is still high among some groups, notably those with public insurance and those with low incomes. For example, one in four nonelderly people devote more than half of their total out-of-pocket health care spending to prescription drugs. These trends suggest that the affordability of prescription drugs under the future insurance exchanges will need to be monitored, as will efforts by states to increase prescription drug copayments under Medicaid or otherwise restrict drug use to reduce public spending.
There are concerns that proton pump inhibitors (PPI) are being over prescribed in both primary and secondary care. This study aims to establish potential cost savings in a community drug scheme for a one year period according to published clinical and cost-effective guidelines for PPI prescribing.
Retrospective population-based cohort study in the Republic of Ireland using the Health Services Executive (HSE) Primary Care Reimbursement Services (PCRS) pharmacy claims database. The HSE-PCRS scheme is means tested and provides free health care including medications to approximately 30% of the Irish population. Prescription items are WHO ATC coded and details of every drug dispensed and claimants’ demographic data are available. Potential cost savings (net ingredient cost) were estimated according to UK NICE clinical guidelines for all HSE-PCRS claimants on PPI therapy for ≥3 consecutive months starting in 2007 with a one year follow up (n=167,747). Five scenarios were evaluated; (i) change to PPI initiation (cheapest brand); and after 3 months (ii) therapeutic switching (cheaper brand/generic equivalent); (iii) dose reduction (maintenance therapy); (iv) therapeutic switching and dose reduction and (v) therapeutic substitution (H2 antagonist).
Total net ingredient cost was €88,153,174 for claimants on PPI therapy during 2007. The estimated costing savings for each of the five scenarios in a one year period were: (i) €36,943,348 (42% reduction); (ii) €29,568,475 (34%); (iii) €21,289,322 (24%); (iv) €40,505,013 (46%); (v) €34,991,569 (40%).
There are opportunities for substantial cost savings in relation to PPI prescribing if implementation of clinical guidelines in terms of generic substitution and step-down therapy is implemented on a national basis.
Proton pump inhibitors; Cost-effective; Guidelines; Generic
Prescription drug costs represent the fastest growing item in health care and are a driving force in rapidly increasing health care costs. Community health centers serve an indigent population with limited access to pharmaceuticals. Pharmaceutical companies sponsor patient assistance programs. These pharmacy assistance programs can be developed to facilitate the provision of needed pharmaceuticals to this vulnerable population. La Casa de Buena Salud is a rural community health center in eastern New Mexico, which has provided access to a substantial amount of pharmaceuticals to indigent patients through patient assistance programs. Cost savings potential are considerable for a community health center and for patients when a pharmacy assistance program is organized efficiently and employed systematically. Secondary benefits are derived from the entire medical community. While some community health centers currently make effective use of pharmaceutical company-sponsored pharmacy assistance programs, a comprehensive, long-term approach at a national level may be required.
Background: Bargain generic programs have proliferated rapidly since 2006. Little is known about the use of these programs. The purpose of this study was to assess the rate and characteristics of prescriptions written in a managed care organization (MCO) to an out-of-plan pharmacy (OOPP).
Methods: This retrospective health services investigation examined characteristics of patients in an MCO who did and did not have a prescription written to an OOPP from October 1, 2006 through September 30, 2010, and patients who had a prescription transferred to an OOPP in September 2008 (only month with data available). Descriptions of the longitudinal rate of OOPP use, OOPP patient and medication characteristics, and OOPPs where prescriptions were transferred are reported. Patient characteristics independently associated with an OOPP prescription were analyzed with logistic regression modeling.
Results: A total of 10,353,283 prescriptions were included. The monthly rate of OOPP usage during the study period increased from 1.5% to 5.2% and then stabilized at around 5%. Prescriptions written to an OOPP were more likely to be for chronic disease states. Patient age and MCO termination were associated with having a prescription written to an OOPP; whereas increasing medication purchases, a drug benefit, and a health maintenance organization plan type were associated with not having a prescription written to an OOPP. More than 80% of transferred prescriptions went to an OOPP with a bargain generic program.
Conclusion: The rate of OOPP prescriptions increased rapidly over the study period. Prescriptions written to an OOPP were predominantly for chronic diseases. Further research is warranted to assess if OOPP use results in reduced quality of health care system oversight or compromises patient health.
Adherence to pharmacotherapy for heart failure is poor among older adults due, in part, to high prescription drug costs. We examined the impact of improvements in drug coverage under Medicare Part D on utilization of, and adherence to, medications for heart failure in older adults.
We used a quasi-experimental approach to analyze pharmacy claims for 6,950 individuals age≥65 years with heart failure enrolled in a Medicare managed care organization two years before and after Part D’s implementation. We compared prescription fill patterns among individuals who moved from limited (quarterly benefits caps of $150 or $350) or no drug coverage to Part D in 2006 to those who had generous employer-sponsored coverage throughout the study period.
Individuals who previously lacked drug coverage filled approximately 6 more heart failure prescriptions annually after Part D (Adjusted Ratio of Prescription Counts = 1.36, 95% Confidence Interval=CI=1.29-1.44; p<0.0001 relative to the comparison group). Those previously lacking drug coverage were more likely to fill prescriptions for an angiotensin converting enzyme inhibitor/angiotensin II receptor blocker plus a beta blocker after Part D (adjusted ratio of odds ratios=AROR=1.73; 95% CI=1.42-2.10; p<0.0001), and more likely to be adherent to such pharmacotherapy (AROR=2.95; 95% CI=1.85-4.69; p<0.0001) relative to the comparison group.
Medicare Part D was associated with improved access to medications and adherence to pharmacotherapy in older adults with heart failure.
Health plans have implemented cost-sharing and administrative controls to constrain escalating prescription expenditures. These policies may impact physicians’ prescribing and patients’ use of these medications. Important clinical advances in the pharmacologic treatment of addiction highlight the need to examine how pharmacy benefits consider medications to treat substance dependence. The extent of restrictions influencing availability of these medications to consumers is unknown. We use nationally representative survey data to examine the extent and stringency of private health plans’ management of naltrexone and disulfiram for alcohol dependence, and buprenorphine for opiate dependence. Thirty-one percent of insurance products excluded buprenorphine from formularies, while 55% placed it on the highest cost-sharing tier. Generic naltrexone is the only substance dependence medication that is both rarely excluded from formularies and usually placed on a lower cost-sharing tier. These findings demonstrate that pharmacy benefits have an impact on access to medications to treat substance abuse.
pharmacotherapy; cost-sharing; pharmacy benefits; formulary; substance abuse