Life Sciences

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

Medicare & Reimbursement Advisor Weekly, August 5, 2009

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.