Timely, topical and in-depth analysis of issues particularly relevant to Medicare Advantage Part D (MAPD) Plans, Employer Group Waiver Plans (EGWPs) and standalone Prescription Drug Plans (PDPs).
and Boost Star Ratings+–
High-risk medications (HRM), also known as high-alert or high-hazard medications, are drugs that have an increased risk of harmful side effects even when used as indicated and for which a safer alternative is available. Controlling their usage will both increase patient safety and boost star ratings. The five-star rating system from the Centers for Medicare & Medicaid Services (CMS) includes a category for Patient Safety and Accuracy of Drug Pricing. A specific measure, known as D14, rates Medicare Part D Prescription Drug Plans (PDPs) and Medicare Advantage Plans (MAPDs) based on the percentage of plan members age 65 and older who fill prescriptions for certain high-risk medications even though safer drug options are available.1
The HRM rate measures the percentage of plan members, as a subset of all plan members, who receive at least two fills for a high-risk prescription medication. It is incorporated as part of a plan’s overall star rating, which can range from 1 to 5 (with 5 being the highest).
CMS treats the high-risk medication measure as an intermediate outcome measure, weighting it three times more than some other measures, including process measures such as enrollment timeliness. Thus, the HRM measure is a high-impact performance area for Medicare Part D plan sponsors. In practice, the HRM star rating is aggregated, along with the star ratings for other outcome and process measures, into a total star rating for a given MAPD or PDP. According to the 2013 CMS technical notes, the national numeric average HRM rates in 2011 were 7.8% for MAPDs and 8.8% for PDPs, which translate to an average star rating of 3.1 out of 5 for both plan types.1
Patient Safety through Prior Authorization
Express Scripts designed its High-Risk Medication Prior Authorization (HRMPA) program in 2011 to drive patient safety by monitoring the real-time dispensing of CMS-classified high-risk medications. The HRMPA program supports plan sponsors’ prior authorization (PA) and medical exception initiatives, offers review services 24 hours a day throughout the year, and gives physicians and pharmacists easy access to PA information.
In 2011, the original HRMPA program monitored high-risk medications in two therapeutic classes: skeletal muscle relaxants and first-generation (sedating) antihistamines. Since then, the Express Scripts program has expanded to align with CMS’s updated HRM list, including PA and step therapy implementations for barbiturates and benzodiazepines. Additional HRMs are being evaluated for inclusion in the future. The figure below shows how our HRMPA program promotes the use of safer alternative prescription drugs at the point of service.
Express Scripts researched the effect of our HRMPA program on the use of high-risk medications among our Medicare plan members. The study involved more than 65 health plan contracts representing more than 2.2 million Medicare lives. Clients with CMS contracts were grouped into two categories based on whether they used the Express Scripts HRMPA program. Similar to the methodology used by CMS in measuring the HRM rate, researchers calculated the percentage of Medicare Part D beneficiaries who received two or more prescription fills for a drug with a high risk of serious side effects in the elderly in 2011. Using an unadjusted test of association (two-sample t-test), the study analyzed whether the numerical averages between the two groups differed on the percentage of high-risk medications that the plan members received.
Results showed that across MAPD and PDP plans, HRM prescriptions were received by 7.4% of members in contracts that did not have the HRMPA program in place, compared to an HRM rate of only 5.5% in contracts that did have the Express Scripts HRMPA program. (See table below.) Notably, Express Scripts MAPD and PDP plans overall — including those without the HRMPA program — dispensed lower percentages of high-risk medications to Medicare beneficiaries than the national averages for their counterpart plans.
On average, beneficiaries whose plan sponsors implemented the HRMPA program had an HRM rate which was 1.9 percentage points less than that of beneficiaries whose plan sponsors did not implement HRMPA (P<0.05). For MAPDs, 5.4% of plan members with HRMPA received high-risk medications compared to 7.1% of those without the program — a significant difference of 1.7 percentage points (P<0.05). For PDPs, the difference was 3.1 percentage points, with only 6.0% of plan members with HRMPA receiving high-risk medications compared to 9.1% of those without an HRMPA program.
Healthier Outcomes and Higher Star Ratings
The evidence clearly shows that plan sponsors can achieve healthier outcomes — and a higher CMS star rating — by strategically using advanced clinical pharmacy benefit management solutions to more effectively monitor and control the high-risk medications that members receive.
In 2011, the oldest of the Baby Boomers – the generation of Americans born in the two decades after World War II – became eligible for entry into the Medicare system as they reached retirement age. As a consequence, after increasing year over year at approximately 1% for several years, the number of Medicare beneficiaries grew 3.7% between 2011 and 2012.1 The U.S. Department of Health and Human Services has estimated that 11,000 Baby Boomers become eligible for Medicare benefits each day.2
Of course, the new wave was long anticipated. And because of its sheer volume – an estimated 78 million babies were born during the Baby Boom3 – the so-called Boomers have shaped many social and cultural aspects of American life, including the structure of the housing market,4 religion5 and the delivery of education,6 to name just a few. Accordingly, there was much concern about the impending onslaught of beneficiaries into the federal healthcare system long before the Boomers began turning 65. The challenge of caring for the vast number of elderly Baby Boomers under the public insurance program, labeled “the 2030 problem,” is the broad umbrella under which concerns about access to certain types of healthcare, physician shortages and financial sustainability have fallen.7,8 By 2030, there will be an estimated 70 million Medicare-eligible Americans, putting additional economic stress on a healthcare system that already has fiscal problems.9
Anticipating a Heavy Burden
Concerns about readiness and capacity have been compounded by recent evidence suggesting that beyond its unprecedented size, the cohort of Baby Boomers presents additional challenges because its members are not as healthy as previous generations of elderly Americans. External data suggest that relative to the prior generation of aging adults, Baby Boomers are more likely to report being obese and having health conditions associated with obesity.10 The medical costs associated with obesity, regardless of age, place economic demands on the healthcare system that have been estimated at $190 billion per year.11 The implications are that if the health of Baby Boomers does not improve, the costs to treat obesity and other conditions among the elderly will bankrupt the Medicare system.
Chronic diseases such as those associated with obesity often require the long-term use of specific medications. In an effort to contribute to the conversation about the potential burden of disease that Medicare may face, we measured the prevalence of and prescription drug use for diabetes, high blood pressure and high blood cholesterol in Baby Boomers of various ages. Medical diagnoses and prescription drug claims from October 1, 2011, through September 30, 2012, from a sample of Express Scripts commercial clients were used to evaluate disease prevalence and prescription drug use.
The research suggests an alarming trend with serious implications for the solvency of the Medicare system: the prevalence of each of the three conditions increases steadily with age.
Prevalence of Disease by Baby Boomer Age Group
Managing to Reduce Overall Spending
Although the prevalence of chronic disease in older adults has undeniable and direct implications for the Medicare program, the good news is that chronic diseases can be managed. At least part of the downstream burden commonly associated with increasing age and worsening disease can be avoided through improved patient behavior, including lifestyle modifications that lead to weight loss, and adherence to prescription medications. In studies, even moderate weight loss was associated with better health outcomes,12 and adherence to prescribed medications has been linked to decreased hospitalization and use of emergency departments.13,14
Improved adherence to medications will contribute only a minimal increase in spending on Medicare Part D, as many medications used to treat diabetes, hypertension and high blood cholesterol are available as generics. The Part D benefit helps to lower overall spending, in part by helping beneficiaries avoid utilization of more expensive healthcare services, such as those provided in emergency rooms and during hospitalizations.15 Through the Five Star Quality Rating System by which it judges the quality of healthcare services provided to Medicare beneficiaries, the Centers for Medicare and Medicaid Services provides financial incentive for adherence to diabetes, hypertension and high cholesterol medications.16
One of the most important ways to potentially ease the financial strain on the Medicare system expected from the influx of 78 million Baby Boomers is to make sure that those who have been diagnosed with chronic diseases and who have been prescribed medications are adherent to their medications.
The increasing availability of lower-cost generic medications offers significant savings opportunities for Medicare members and plan sponsors. But unless those new drugs are prescribed or authorized, the financial benefits of generics cannot be realized.
What Drives Prescriber Choices?
Several factors influence the type and quality of medical services you are likely to receive as well as how much the services will cost. These influences include where you live, which physician treats you and which hospital you select.1 Express Scripts researchers wondered if similar patterns exist for the prescribing of prescription drugs. To put it simply, do location and other characteristics of physicians influence which medications they prescribe? We were specifically interested in whether physicians choose to prescribe generic medications for some of the most costly and common conditions.
To identify the specific factors that influence the behavior of Medicare prescribers, Express Scripts designed a study of the prescribing patterns for medications for diabetes, hypertension and high cholesterol. We sought to answer the question, “What is it about prescribers that influences generic utilization by their patients?” Our research revealed that prescribing practices and generic fill rates (GFR) – the proportion of prescriptions written for generic medications – appear to be affected by a variety of internal and external factors, such as where a prescriber practices and whether the prescriber is a generalist or a specialist.
The study looked at all healthcare providers in the United States (physicians, nurse practitioners and physician assistants) who had written at least 30 prescriptions in a calendar year for medications used to treat diabetes, hypertension or high cholesterol. First, a disease-specific GFR was calculated for each prescriber. Then, we assessed each prescriber’s Medicare penetration rate – the proportion of the prescriber’s patients who were Medicare beneficiaries. We also gathered information on each prescriber’s age, tenure and geographic location so we could evaluate the influence of demographic and environmental factors on the prescriber’s GFR.
Multiple Factors Influence Generic Utilization
The study found that prescribers who were older and who had longer tenure tended to prescribe fewer generic medications than did younger, less tenured prescribers. One potential explanation for this finding has to do with habit and experience. Some healthcare providers have been practicing medicine longer than many generic drugs have been available. Along similar lines, although the cost of medications has become an increasing focus in healthcare and on the national stage, physicians are often unaware of how much drugs cost.2 Physicians and other prescribers therefore may simply prescribe the brand drugs with which they are familiar and that have worked well for their patients out of habit – without any thought to the added cost of a brand drug over its generic equivalent.
Medicare prescribers who treated large Medicare populations also had higher GFR, which is likely the result of the Centers for Medicare and Medicaid Services formulary management guidelines, which promote generic equivalents and recommend placing brand-name drugs in lower tiers within formularies where appropriate.3 The benefit is that this leads to the diffusion of prescribing practices to non-Medicare patients as well.
The most interesting finding of this study was that a prescriber’s geographic location was a strong predictor of the proportion of generic prescriptions he or she wrote. Location encompasses many features that have a complex influence on prescribing and utilization. Factors include the income of local residents, the influence of media markets and advertising dollars, and the proximity to urban centers and the healthcare amenities offered there.
Our study revealed that prescribers practicing in New York and New Jersey, in addition to those practicing in southern states such as Texas and Louisiana, had consistently lower GFRs than their counterparts in midwestern states such as Ohio, Wisconsin and Iowa. Evidence of geographic variation in prescribing practices has been noted in earlier studies and may be related to the concentration of medical facilities and the presence of pharmaceutical companies.
Those locations each determine different marketing and prescribing patterns,4 and are concentrated heavily in states with some of the lowest GFRs. Further, prescribers who practiced in rural areas adjacent to large cities had higher GFRs than did prescribers practicing in metropolitan areas and urban centers. Prescribing lower-cost generic medications rather than brand medications may be a necessity for providers who treat patients in nonmetropolitan areas inasmuch as the concentration of poverty in rural areas continues to grow.5
The Patent Cliff: Potential for Enormous Savings
In 2012, an unprecedented number of branded blockbuster medications lost patent protection. Among these were several drugs heavily used by the Medicare population, including Plavix® (clopidogrel), a blood thinner used to prevent blood clots, and Seroquel® (quetiapine), an atypical antipsychotic also used to treat major depression. As a result, there is tremendous potential for savings for both Medicare beneficiaries and plan sponsors: nationwide there are 49.4 million (and growing) Medicare beneficiaries, 81.3% of whom are enrolled in Medicare Part D programs to cover the cost of their prescription drugs. Moreover, prescription medications represent 12.2% of Medicare spending.6
Express Scripts manages benefits for more than 5 million Medicare beneficiaries, and we work along with our plan sponsors to find the safest, most affordable way to provide prescription drugs to these patients. We have found that Medicare benefit plan management that favors generic drugs – including intentional formulary management and the adoption of home delivery programs – has the potential to enable better health outcomes while saving money for patients and plan sponsors. We believe as well that there are ways to help educate physicians about lower-cost, clinically effective alternatives that will help them make better prescribing decisions. Our findings regarding the geographic variation in prescribing patterns suggest that attempts to increase the rate at which physicians prescribe generic alternatives will likely require different interactions and interventions, and that the success of these kinds of efforts may vary by region.