Evidence from a Pharmacy Access Program TERESA B. GIBSON, PHD SENIOR DIRECTOR, HEALTH OUTCOMES OCTOBER 27, 2011

Transcription

1 Evidence from a Pharmacy Access Program TERESA B. GIBSON, PHD SENIOR DIRECTOR, HEALTH OUTCOMES OCTOBER 27, 2011

2 OVERVIEW Gibson TB, Mahoney J, Ranghell K, Cherney BJ, McElwee N. Value-Based Insurance Plus Disease Management Increased Medication Use and Produced Savings. Health Affairs. 30(1): January 2011 Extensions to this study 2

3 BACKGROUND Employers must develop innovative ways to overcome barriers to corporate competitiveness and economic sustainability Health care costs Chronic disease burden One strategy is value-based insurance design The explicit use of employee benefit incentives to encourage individuals to use high value health services, adopt healthy lifestyles, and/or to select high performance providers. (National Business Coalition on Health, 2009) 3

4 BACKGROUND A number of employers and payer organizations have implemented value-based insurance design programs Incentives can include rewards, reduced premium share, adjustments to deductible and copayment levels, and contributions to fund-based plans, such as Health Saving Accounts 4

5 BACKGROUND Diabetes is a chronic condition affecting 7.8% of the US population. (Am. Diabetes Association 2010) It is a costly condition and medication therapy is often warranted Diabetes has been a focus of many value-based pharmacy programs Evidence of the effects of various diabetes valuebased insurance design programs is beginning to emerge 5

6 BACKGROUND Within a year of reducing generic copayments to $0 and brand name copayments by 50% the diabetes medication possession ratio rose 5.79 percent (Chernew et al. 2008) Moving most diabetes medications and supplies into a single $10 per fill tier resulted in a 30% reduction in the number of nonadherent patients in the first year The patient sample affected by VBID (n=71) (Zeng et al. 2010) 6

7 BACKGROUND A value-based pharmacy program where cost sharing for generic and preferred brand name diabetes medications were lowered found that in the first year of treatment, patients were more likely to start on medications, discontinuation rates fell and the Medication Possession Ratio rose for participants in (Chang et al. 2010) 7

8 BACKGROUND Disease management programs are another employer-based intervention that aims to address chronic illness by: supporting healthcare interventions promoting preventive care providing individuals with the resources needed to maintain health Disease management programs may be used in strategies to promote the effective use of healthcare services 8

9 BACKGROUND A review of the peer-reviewed literature on the effectiveness of disease management conducted in 2007 concluded: (Mattke et al. 2007) there is consistent evidence that disease management programs improve the process of care there was no demonstrated impact on outcomes and an uncertain impact on costs Targeted disease management programs may be more effective (Piette 2005) Combined strategies such as disease management and incentive-based programs show promise (Chernew et al. 2008) 9

10 PHARMACY ACCESS PROGRAM Diabetes Disease Management A voluntary diabetes disease management program introduced for all individuals covered under their medical plan on January 1, 2006 Consists of targeted mailings, a condition-specific workbook, telephonic outreach by a nurse, additional educational mailings, coaching and periodic monitoring Diabetes Value-Based Design Offered to employees and their dependents in two large US-based units (covering 33,160 enrollees) 59,038 enrollees not offered the value-based design Lowered cost-sharing for all diabetes medications to 10% coinsurance, from a 10% generic/20% preferred brand/35% nonpreferred brand tiered structure. 10

11 STUDY AIMS Estimate the effects of the VBID within two groups of enrollees with diabetes: those with and those without disease management. Estimate the effects of the VBID on brand name antidiabetic medications and generic antidiabetic medications? Own- and cross-price elasticity of a decrease in brand name medication cost-sharing on the utilization of brand name and generic medications Previous research of the effects of an increase in brand name cost sharing has revealed a variety of effects on generic utilization (Gibson et al 2010) 11

12 METHODS Data Source Thomson Reuters Advantage Suite employer data warehouse consisting of enrollment data, healthcare claims data and prescription drug claims data Patient Selection Enrollees under 65 years of age that had at least 4 contiguous quarters of enrollment in

13 MATCHED COMPARISON GROUPS VBID with Disease Management : No VBID with Disease Management (comparison) VBID without Disease Management: No VBID without Disease Management (comparison) Propensity Score matching (Rosenbaum and Rubin 1983) Summarized score Pr(intervention group X)=F(sociodemographic, plan type, health status, length of enrollment) One-to-One Matching 13

14 FRAMEWORK A panel data file was constructed with enrollee as the cross-sectional unit and calendar quarter as the unit of time Enrollee experience measured in quarterly increments throughout their enrollment time frame or through the end of December

15 MEASURES Medication Utilization/Adherence Oral antidiabetic medications (brand/generic) Insulin Diabetes Guideline Recipients HbA1c testing, lipid tests, and urinalysis Office Visits Retinal eye exams Payments (Total, Diabetes-Related) Medical Prescription Drug 15

16 PROGRAM EFFECTS Multivariate Generalized Estimating Equations (GEE) Y = f(program, Program*time, no VBID, X, quarter) Program - 1/0 variable indicating the quarters where the program was in effect and indicates the effects on the overall level of the measure. Program*time, indicates the number of quarter since program inception represents any time varying effects of the program No VBID - 1/0 variable indicating that the enrollee belonged to the comparison group and estimates fixed effects common to both groups or unique to the comparison group X sociodemographic characterisics, plan type, health status 16

17 RESULTS With Disease Management No Disease Management VBID No VBID p value VBID No VBID p value N = 1,876 1, Mean follow up (in quarters) Mean Age Sex Male 59.4% 58.5% % 57.9% Female 40.6% 41.5% % 42.1% Insurance Plan Type Comprehensive 12.6% 13.3% % 7.0% EPO/POS 8.1% 7.8% N/A N/A HMO 33.2% 32.8% % 68.6% PPO 46.1% 46.1% % 24.4% Region North East 24.5% 21.3% % 40.2% North Central 10.4% 11.0% % 12.2% South 55.5% 57.4% % 43.0% West 9.6% 10.3% % 4.6% Relation to Employee Employee 63.7% 63.1% % 61.0% Spouse 32.0% 32.2% % 34.5% Dependent 4.3% 4.7% % 4.6% Clinical Characteristics Charlson Comorbidity Index # Psychiatric Diagnosis Groups

18 RESULTS The combination of VBID and disease management is more powerful than disease management alone Prescription drug utilization All antidiabetic medications Oral antidiabetic medications Insulin Brand/generic antidiabetic medications Adherence to recommended medical service guidelines PCP Visits, HbA1c tests, Urinalysis, Lipid tests Retinal eye exams unaffected Patients may have been using vision care benefits (not medical benefits) to receive eye exams 18

19 RESULTS: PRESCRIPTION DRUG UTILIZATION HbA1c Test Lipid Test PCP Visit Urinalysis 19

20 RESULTS: BRAND AND GENERIC ANTIDIABETIC MEDICATION USE Increase in the utilization of both generic and brand name medication use in each of the three follow up years (p<0.05) Increased medication management (PCP visits also increased) In previous studies, generic medications have been observed to be substitutes and complements to brand name medications Income effects Availability of generic medications Treatment conventions 20

21 RESULTS: BRAND NAME ANTIDIABETIC MEDICATIONS 21

22 RESULTS: GENERIC ANTIDIABETIC MEDICATIONS 22

23 RESULTS: GUIDELINES HbA1c Test Lipid Test PCP Visit Urinalysis 23

24 RESULTS: SPENDING VBID and disease management group All-cause prescription drug spending rose after implementation All-cause medical spending was unchanged after implementation Net effect on medical plus drug spending was unchanged or cost-neutral. Diabetes-related prescription drug spending rose and diabetes-related medical spending dropped in each year after implementation Spending effects for the VBID group without disease management were cost-neutral 24

25 RESULTS: DIABETES-RELATED SPENDING EFFECTS VBID and Disease Management Compared to Disease Management 25

26 RESULTS: VBID WITHOUT DISEASE MANAGEMENT The effects on those who opted out of a diabetes disease management program (VBID with no disease management compared to no disease management) resulted in higher levels of adherence to a 0.8 MPR threshold or higher, but no other lasting effects among other measures. Among those who opted out, the sample size was smaller (n=328), which may have reduced statistical power The majority were enrolled in an HMO (tighter medical management) 26

27 LIMITATIONS Limitations associated with administrative data Single employer study Opt-in to disease management Some patients in the disease management group may not have been filling prescriptions for diabetes medications at the onset of the program 27

28 CONCLUSIONS This study offered a unique opportunity to assess the effects of a value-based pharmacy design in two business units of a large, multi-site firm. It was possible to construct four study cohorts consisting of individuals with (or without) disease management combined with (or without) the VBID pharmacy plan. It was possible to follow longer-term (3-year) effects. The combination of diabetes VBID and disease management programs for patients who opt into the disease management program produced improvements in medication adherence and guideline adherence over time. 28