Models for Effective Medication Use in Health Care Systems

1
Models for Effective Medication Use in Health
Care Systems

• Susan J. Curry, Ph.D.
• University of Illinois at Chicago

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• Models for effective medication use in health
  care systems for treatment of tobacco use and
  dependence should be consistent with models for
  treatment of other chronic conditions

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Chronic Care Model
4

• Medication can be used effectively if it is
• Available
• Affordable
• Appealing
• Appropriately used

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Making Medications Available Formulary
Decisions

• Prescription drug costs up 19 in 2000
• 36 of increase due to new, drugs
• higher drug costs not offset by lower medical
  costs
  
• Insurers MCOs control costs and outcomes by
  making evidence-based decisions on whether to
  place new drugs on formulary

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Formulary decisions

• Focus on clinical outcomes as well as economics
• Made by committee
• Use standardized guidelines

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Regence BlueShield Formulary Guidelines

• Regence clinical pharmacists complete detailed
  review of each drug based on clinical
  literature.
  
• Medical literature on efficacy, effectiveness and
  relative safety is foundation for formulary
  review
  
• FDA AB rated generics will generally be
  preferred

Mather et al, A J Man Care, 19995(3)277-285
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Regence BlueShield Formulary Guidelines

• Brand names only included when offer value (e.g.,
  significantly more clinically effective than
  generics or other brands in the same therapeutic
  class)
• When clinical studies show that several drugs are
  clinically equivalent, only the products with the
  lowest net cost will be included in the formulary

Mather et al, A J Man Care, 19995(3)277-285
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Regence BlueShield Formulary Guidelines

• Improved dosage forms only considered when their
  cost effectiveness can be documented
  
• For each drug, manufacturers are required to
  submit dossiers that include detailed clinical
  and economic information, including data from
  published and unpublished studies, and outcomes
  modeling

Mather et al, A J Man Care, 19995(3)277-285
10
Regence BlueShield Formulary Guidelines

• Economic modeling will be used to evaluate the
  impact of each drug on patients clinical
  outcomes, medical claims, and costs of care.

Mather et al, A J Man Care, 19995(3)277-285
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Formulary decisions bottom line

• Burden of proof is on the medication (and, by
  extension the manufacturer)
  
• As number and types of pharmacotherapies for
  tobacco use cessation increases there will be
  increasing demand from health systems for data on
  their relative clinical and cost effectiveness

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Making medications affordable Insurance coverage

• Use goes up with full coverage
• 25 vs. 14 used NRT over 12 months (Schauffler
  et al, Tob Cont, 2001)
  
• But not always
• 19 vs. 24 used Zyban
• 28 vs. 26 used NRT over 12 months (Boyle et
  al, Health Affairs, 2002)

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Making medications affordable Insurance coverage

• The more it costs, the less its used
• 50 co-payment on NRT associated with 31 drop in
  use (Curry et al, NEJM, 1998)
  
• Many with coverage dont know they have it
• 30 in Boyle study knew of coverage
• Use of medications higher if aware of coverage
  (42 Zyban 31 NRT)

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Making medications affordable Insurance coverage

• How benefit is structured can impact availability
  and use of new medications
  
• Bundled with behavioral program
• Coverage for specific medications or all
  FDA-approved
  
• Amount dispensed per prescription

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Making pharmacotherapy appealing

• Does prior failure with pharmacotherapy reduce
  demand for new treatment?
  
• National data not available, but RTC data suggest
  not
  
• Over 60 of volunteers for Zyban effectiveness
  trial had prior use of NRT
  
• Pharmacotherapy may have inherent appeal to
  smokers looking for the magic bullet

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Making pharmacotherapy appealing

• Pharmaceuticals investments
• Direct-to-consumer marketing
• Academic detailing for clinicians
• Health care system investments
• vital sign stamps, chart stickers for easy
  identification of smokers
  
• medical record prompts for advice, assistance
• clinical information systems and registries for
  follow-up

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Facilitating appropriate use

• Medication approval in efficacy trials
• face-to-face prescribing
• regular monitoring behavioral support
• Medication use in effectiveness conditions
• over-the-phone prescriptions
• under-dosing (amount /or duration)
• concurrent smoking
• no behavioral support

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Facilitating appropriate use Behavioral support

• Bundled coverage ensures behavioral support
• Seamless protocols for obtaining pharmacotherapy
  as part of behavioral program ensures medication
  use
  

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Facilitating appropriate use Behavioral support

• Integrated Model
• Telephone-based enrollment screening for
  medication eligibility
  
• case review for questionable, ineligible by
  program physicians
  
• notification of potential medication use to
  patients primary care provider
  
• Medications and written behavioral program
  materials sent by mail

From Swan, McAfee, Curry et al, Arch Int Med (in
press)
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Facilitating appropriate use Behavioral support

• Integrated model, contd
• Patient enrolled in state of the art telephone
  counseling program(4 outreach calls over 6
  months access to toll-free quitline for 1 year)
  
• Treatment progress reports sent to primary care
  physicians
  

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Facilitating appropriate use Behavioral support
Dose OR 1.05 0.94,1.17
Program OR 1.21 1.08,1.35
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• Moderate intensity behavioral programs do improve
  long-term outcomes
  
• Can be provided in-house or through linkages
  with community-based programs (e.g., state
  quit-lines)
  

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Re-cap

• Medications must be available
• May be a higher bar for new medications
• Affordability is important
• Particularly for lower income smokers where
  prevalence is increasingly concentrated
  
• Chronic disease care models in health care
  systems are appropriate
  
• Behavioral (self-management) support is a key
  component