Life Sciences

Medicare & Reimbursement Advisor Weekly, August 5th, 2009

Medicare & Reimbursement Advisor Weekly, August 5, 2009


Beyond the contract: Can habit-changing service affect script, formulary decisions?

Home health segment focuses on QI teams

Conversation: Commercial policies, economy affect site of care

Account manager insight: Facilitating C-suite quality initiatives

LTC: Frontline staff members take larger role in product selection



Beyond the contract: Can habit-changing service affect script, formulary decisions?

Minus a first-line drug, what we’re all trying to achieve here is brand differentiation. The job has to be about helping patients get the medicines they need to live free, happy, and productive lives. We’re all on the same page in this way, but so often we sit in silos within our businesses and between stakeholders. It’s refreshing when the silos break down for a moment and an idea becomes a proposal, which then becomes a pilot, and leads to a model that changes behavior and, ultimately, outcomes.

That’s the gist of a new program designed to help patients adhere to medicines. In this report, we’ve gathered initial managed care feedback from our advisors (see charts on pp. 2–3), so as you read their reactions, think of how your ideas and programs can adapt.

The background

Primary Health Network has 35 clinics in Pennsylvania and Ohio and its insurer, Highmark BCBS, works with the employer to incent all employees to use Habit Care, a behavioral change system using Web, phone, mail, and community support to affect physician-prescribing behavior for branded products, support favorable payer formulary decisions, and bolster medication adherence. Physicians surveyed in July 2009 said that if a prescription has a Habit Care follow-up component this service could affect their prescription decisions—scripts could basically double. (Details about Habit Care appear at the link at the end of this story.)

Survey respondents were given a specific scenario based on their specialty. The fol- lowing is a general version of what each doctor read:

Consider a scenario where prescriptions to certain medicines also include patient access to a free one-year behavioral change service. The service is based on four well-studied approaches to behavioral change: The Transtheoretical Model, Self-Determination Theory, Cognitive Behavioral Therapy, and Coaching. The service provides scientifically validated advice to help patients adhere to medication therapies, change their diet, and exercise. It helps patients set goals and track progress.

The physicians were then given an opportunity to stipulate how such a program would affect product selection. The following responses are from four physician participants.

Adoption unlikely if payers don’t support

Physicians today often have multiple good- drug options for a condition, so the ability to offer patients a service to reduce complications and unpaid readmissions is attractive.


“Diovan is a great drug, and I will worry less about the price versus a generic ARB if Diovan offers additional value, like this program,” said one of the primary care physicians (PCP).

Michael Yanuck, MD, a consultant for managed care, hospitals, and drug companies, said: “This is interesting since there are no generic ARBs.”

On Byetta, “it has some good data, but I’m hesitant to use it for injection-fearful patients. I’d be willing to try it more with this program in place,” another PCP noted.

Dr. Yanuck said, “I agree with this doctor’s view.”

Managed Care Medical Reaction

The following comments are from Dr. Yanuck:

  • One immediate question I would have is what type of patients we’re talking about here? Are the last 10 in the scenario highly managed or nonmanaged care? Are these 10 hypothetical patients all with Medicare Part D, commercial, self-pay, or no insurance?
  • I won’t prescribe Vytorin, for example, if the patient can’t afford it, but if the patient has BlueCross and a $10 copay, then the program probably adds value in that context.
  • Looking at the Byetta and Vytorin examples, I’m wondering why if this program is so good, why the numbers aren’t 10 across the board. Perhaps this takes into account the mix of prescription coverage/copay issues for each patient.
  • A managed care plan may not want to see a ton of utilization for a branded product. In Byetta’s case, where there is no generic, obviously the plan would like to see a program that adds value such as this. In classes filled with generics, the plan would rather see the generic offer this program rather than having scripts going up for a more costly brand.
  • It will be important for the physicians to understand who is conducting the follow-up (such as a licensed mental health counselor for the depression scenario). For managed care, the plan will want to see a feedback loop back to the MD. With Byetta, for example, the program must return information back to the physician about cases in which the patient is not adherent or not filling the script.
  • One obvious positive here is that this program focuses on some very good chronic diseases. If the program can prove it builds adherence and strengthens medication management and prevents complications downstream, then it will get our attention. A pilot would be critical to get payer support. If out of 100 patients in a control group 20% are adherent, and in the test group (those utilizing the behavioral follow-up service), 70% are adherent, then you have a model. A difference of 30% to 40% between groups would mean the program doesn’t work. For the depression piece, the testing could assess HIMD (hormone-induced manic depression) scores and how they compare for those receiving cognitive behavioral counseling versus those in the control group.
  • We need to see how this model controls costs. In a class with generics, why—when I can pay 10 cents for the generic—would I pay higher for the brand? I’d have to see how the program saves.

Managed Care Pharmacy Reaction

The following comments are from Dan Renick, RPh, at The Hobart Group: There is obviously interest in empowering providers and patients to resist a generic switch. That’s important if the brand is more appropriate clinically. If the program has the potential to improve compliance and adherence and also control utilization then, from a managed care perspective, it has merit, but I’m not sure about the financial value this specific program will ultimately have for the brand.

Physician Perspective

The following comments are from Joel Brill, MD, chief medical officer at Predictive Health: To me, it appears this product has several goals: to influence prescriber behavior and improve medication adherence and compliance. But given that physicians are slowly moving to e-prescribing, if they have two-way messaging with the ability to send prompts when the preferred drug is not chosen, this e-technology would reduce the need for this program over time. Note: Visit pharma/HabitCarePharma.pdf.



Home health segment focuses on QI teams

In a survey of 324 home health agencies, including the top organizational chains (see chart on p. 5), the following are some of the topline findings. There are opportunities for manufacturers interested in this segment to align with agency quality goals. Some pharmaceutical companies are looking at this segment as an emerging area for growth:

  • 90% of home health agencies/companies put quality improvement (QI) plans in place if desired clinical outcomes (benchmarks) are not met (10% don’t).
  • Of agencies/companies that put plans in place, 91% have a QI team overseeing the plans.
  • 79% of agencies collect outcomes data by diagnosis, 15% by acuity, and 6% use both methods: 67% track outcomes on a nurse-specific level.
  • 82% have a process to follow up with patients within one week after home health discharge. They track hospital admissions, unplanned physician visits, and falls.
  • 98% of home health agencies/companies have internal staff members performing audits on clinical documentation and the care that is provided, including medication management; while 2% use a third party.
  • 94% of home health agencies/companies collect data on the patient’s satisfaction with the care they received during follow-up (6% don’t).
  • 71% of home health agencies/companies have a formal strategic planning process. The formal strategic planning process occurs annually for 79% of this number; 92% of this number include QI as a strategic planning goal, and medication access/better medication management is part of the QI process. One of the major goals ahead for home health agencies is to enhance medication management and training.
  • 68% of home health agencies/companies are receptive to receiving educational support from pharmaceutical manufacturers, provided the education is not brand-specific and aligns with their quality initiatives; they say category-specific education is needed, particularly in the chronic disease areas such as depression.
  • 32 respondents whose agencies/companies use vendor software to ensure that patient assessments/files are compliant prior to billing use McKesson (this was the most common vendor listed). Most respondents are satisfied with McKesson.
  • 99% of companies provide staff member education to protect against adverse events. Only 24% of agencies use a proprietary system to protect against adverse events.
  • 80% do not currently work with any membership associations.

The survey was conducted electronically during the week of July 27 by HCPro, Inc.’s sister company, Beacon Health (, which provides training, news, resources, and consulting for home health nursing and administrative staff members.




Commercial policies, economy affect site of care

How drug cost, climate affect myelodysplastic syndrome patients

by Bryan Cote

Urban medical and academic centers are concerned that the economy and/or job loss has forced people to delay doctor visits and hold off reporting symptoms. Susan Buchanan, MS, PA-C, adult leukemia physician assistant at the Dana-Farber Cancer Institute in Boston, says a 5%–10% drop in new patient consults for adult leukemia is being noticed, as well as fewer second opinion consults (perhaps due to travel expenses), and an increase in Medicaid patients from New Hampshire and Maine—two states severely hit with unemployment since December.

“Leukemia symptoms like bruising don’t always show up so with [primary care physician] visits down due to the economy, there have been fewer physicals, which means fewer CBCs ordered—reducing the likelihood that a physician could catch an abnormal blood count,” Buchanan says.

Buchanan and her physician colleague are used to seeing four new patients per week, about half for myelodysplastic syndrome (MDS). “These numbers have remained relatively steady since patients often request my MD, but overall for the four physicians in our group, visits were down,” she says.

Interestingly, Dana-Farber is seeing growth in the number of complex cases for rare leukemia and bone marrow transplants—the result of commercial payers’ policies to encourage physicians to refer these types of cases to institutions with larger volumes and more developed infrastructure and expertise. This growth at Dana-Farber has offset some of the dip on less complex cases. “It tells me that our new patient volume would be much lower without these cases,” Buchanan says.

In some ways, treating patients with MDS has become more difficult in the economic downturn since patients, and some doctors, are either uneducated about the disease or are faced with a difficult financial decision, says Buchanan.

According to the American Cancer Society, about 40% of patients with MDS convert to full-blown leukemia and of all newly diagnosed MDS patients annually (approximately 14,000 in the United States), about 10%–15% have deletion 5q cytogenetic abnormality, which essentially means they are missing the long arm on the fifth chromosome. If the 5q is their only abnormality, Buchanan says Revlimid (lenalidomide; Celgene) has worked well in about 50% of cases to either eliminate the abnormality or improve blood count so much that the patient no longer needs transfusions.

The cost to use Revlimid (lenalidomide; Celgene) per month is significant (The Wall Street Journal, July 1, 2006, “Celgene to Price Cancer Medicine at $6,195 a Month”), so seniors with Part D benefits hit the catastrophic cap almost immediately and, unless they can get patient assistance, are forced to pay a large portion out of pocket. “This is a lot financially to bear for a treatment that is not guaranteed to provide a patient benefit,” says Buchanan, adding that Celgene has been generous with patients who can’t afford the drug. Sometimes, underinsured patients make too much to qualify, however, and have elected to halt treatment.

Alternatively, Vidaza (azacitidine; Celgene) and Dacogen (decitabine; Eisai) are two other treatment options indicated for those with MDS, but some community physicians have not given Vidaza enough time for proper trial efficacy, says Buchanan. “Based on the CALGB clinical trial data presented by L. Silverman in 2006, and in our experience, patients need four cycles, one per month, before we compare bone marrow results to baseline. Unfortunately, some oncologists who don’t see blood count improvement after two cycles stop the course and try something else,” she says. Many oncologists are now educated on the four-cycle benefit since the FDA approved the drug in 2004. Buchanan thinks patients are less likely to stop Vidaza or Dacogen treatment for financial reasons since these injectables are delivered under a hospital Medicare Part A or in-office Medicare Part B benefit.

Editor’s note: The full story is in July’s Oncology Business Review.


Here’s a new resource to quickly search for Medicare rules, regulations, and CMS documents. Check it out at If you’d like me to arrange a Web-based tutorial to walk you through it, e-mail



Account manager insight

Facilitating C-suite quality initiatives

As more hospitals cut their budgets, account managers and brand teams focused on these institutions may need to understand what to illustrate when making a case for joining a new initiative, launching a new quality improvement program, or building resources in the name of patient safety. “Realize that CFOs now are more abreast of the clinical issues, and not just a number cruncher as they were 10, 15, or 20 years ago,” says John Domansky, CFO at Knoxville (IA) Hospital and Clinics. “There’s a lot more of a balanced approach now in the CFO world than there was in the past.” Domansky, who makes financial decisions for a critical access hospital licensed for 25 beds, says that he is interested most in programs that will minimize the hospital’s risk, and in that vein, he’ll pay more attention to those programs emphasizing a proactive approach to patient care (e.g., arguing for a bar coding program for medications to prevent potential medication errors). For the full article, click here: content/235054/topic/WS_HLM2_FIN/How-Do-You-Gain-a-CFOs-Support-for-Quality-and-Patient-Safety-Programs.html.

To brainstorm building a quality initiative with hospitals’ and health systems’ C-suite in your market, contact the editor.



LTC: Frontline staff members take larger role in product selection

If you market or sell to the long-term care (LTC) segment (or if you’re considering this), be advised: Adopting similar strategies and messaging you use for the acute care or physician practice setting won’t work.

LTC facilities differ from other healthcare settings in virtually every possible way; they are staffed and reimbursed differently and treat sicker, more clinically complex patients. Nursing homes’ clinical decision-making process is nearly as complex as the patients they treat.

Although every Medicare-certified nursing home is required to retain the services of a medical director, physicians aren’t necessarily the primary drivers of medical decisions in LTC. Nursing homes provide long-term, intensive, round-the-clock care to often frail and very sick patients. These patients receive medical and personal care from several providers, including nurses, therapists, certified nurse assistants (CNA), social workers, and dietitians. Most facilities rely on interdisciplinary teams, including the director of nursing (DON), a consultant pharmacist, the patient and his or her family, and the MDS coordinator, who oversee documentation and reimbursement (

RN role in disease recognition

In this clinically complex patient population, the potential for new diseases and conditions, cognitive and physical decline, and adverse reactions is high. Frontline staff members are often the first to notice and report these changes. In fact, in a recent HCPro survey, 87% of respondents reported that floor nurses are involved in resident disease recognition, whereas 67% responded that the facility medical director is involved. Sixty-three percent of respondents reported that CNAs are the first to recognize and report changes in a resident’s mental, physical, and emotional state.

Even with such complicated issues as medication regimen monitoring, LTC nurses are acutely involved in decision-making processes. Seventy percent of our survey respondents reported that their floor nurses are primarily responsible for monitoring a resident’s medication regimen—only 12% indicated that the medical director is primarily responsible. Further, 43% of 287 responding facilities said nurses are “extremely influential” in medication decisions; 98% of respondents indicated that the nurses in their facility are involved on some level in decisions regarding a resident’s medications.


The clinical decision-making picture in LTC facilities is complex at best, but the marketing and sales message is simple: Understand the patients they treat and how care is delivered. Doctors and pharmacists are important, but so are the frontline caregivers who interact with the residents on a daily basis. No matter which marketing/selling tactics you use, remember that no campaign is complete without considering frontline staff members.

Editor’s note: Feel free to write or call to dive deeper into these questions and findings at or 860/232-6377.