Life Sciences

Did adherence survey forget about formulary influence?

Medicare & Reimbursement Advisor Weekly, December 11, 2009

Editor’s note: Someone contacted me recently about a new program designed to help patients adhere to medicines. I’ve put some background information below, plus reaction from a few clinicians about the managed care perspective. What’s interesting is that there seem to be some basic gaps in the actual research that was conducted and the claims made. We thought this might be a useful discussion to bring up internally or with customers.


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.

(Note: Details about Habit Care can be accessed from the link at the end of this story.)

Survey respondents were given a specific scenario based on their specialty. The following 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.

Survey method

This was a Web-based survey, with 113 primary care physicians responding; 89 psychiatrists. The goal was to understand whether Habit Care’s model would change prescribing behavior. Each physician was asked a range of prescribing scenarios based on treating patients with high cholesterol, depression, hypertension, and diabetes. For example, one question asked, “To how many of your last 10 hyperlipidemia patients did you prescribe Vytorin®?” In the follow-up, “How many of the 10 would have received Vytorin if Vytorin included a one-year subscription to this free Habit Care service?”

Similar questions were asked about Byetta® (diabetes), Diovan® (hypertension), PristiqTM (depression), and Cymbalta® (anxiety). In almost all cases, the physicians said they would choose the branded product twice as often if the Habit Care program were available. This is quite a claim.

Michael Yanuck, MD, a consultant from Tampa, FL, for managed care, hospitals, and drug companies shared his reaction:

“One immediate question I would have is what type of patients we’re talking about here,” Yanuck said. “Are the last 10 in the scenario highly managed or non-managed 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.”

Editor’s note: This seemed to us to be a gap in the survey, in the method.

  • 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 of this program rather than having scripts going up for a more costly brand.
  • For managed care, the plan will want to see a feedback loop back to the physician. 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.
  • Yanuck thought 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%– 40% between groups would mean the program doesn’t work, Yanuck said. For the depression piece, the testing could compare those receiving cognitive behavioral counseling versus those in the control group, among other comparators.

Joel Brill, MD, chief medical officer at Predictive Health, said 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.Such e-technology would reduce the need for this program over time.

Former Humana pharmacy director, Dan Renick, RPh, now withThe Hobart Group, said there isobviously 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 notsure about the financial value this specific program will ultimately have for a brand,” said Renick.

Here’s a link to the program and full survey: