David Calabrese, RPh, MHP

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Pharmacy care has always played a critical role in supporting patients’ access to needed services and overall health. At the onset of the COVID-19 pandemic, pharmacies’ ability to proactively engage and monitor patients became even more important as we saw a significant drop in the number of prescriptions filled, an increase in provider and pharmacy access challenges, and a greater need to monitor and protect high-demand medications.

As restrictions are lifted across the country, I anticipate many pharmacy care services that evolved to meet market needs brought on by COVID-19 will continue. Digital platforms, home care services, prescription home deliveries and behavioral health support tools have helped pharmacies provide more affordable, higher quality, more efficient care.

Digital health services, including telehealth and remote monitoring, quickly transitioned from a “value add” to a “must-have” during the pandemic. Nationally, consumers of all ages appear more comfortable and willing to engage digitally than before. We’ve seen this among Optum members, with an 86% increase in first-time users of OptumRx virtual capabilities, such as digitally transferring chronic medications from retail to home delivery. In addition, nine out of 10 of our community pharmacies serving patients with mental health, substance use
disorders and other complex, chronic health conditions are using telehealth to provide more care.

As users’ comfort level and experience grow, virtual engagement and empowerment tools will continue to advance. Although some providers previously did not offer telehealth options, many are now incorporating it permanently into their practices, creating a more integrated e-pharmacy experience that supports ongoing patient monitoring, enhanced medication adherence and reduced risk of viral transmission.

Analysis of medical claims data shows marked reductions in both physician office- and clinic-based outpatient visits during the pandemic, which has led to a substantial decrease in provider-administered drug utilization. The value of in-home services, such as home infusions, has become apparent. They are a potentially safer, less disruptive and more cost-effective alternative to provider-administered medications, particularly for individuals at higher risk.

Home care was already growing, partly as a precaution against infections acquired in hospitals. COVID-19 accelerated the trend. Home care’s flexibility and convenience will keep that momentum going. It can prevent infection, and research has shown home care can also cut medical and pharmacy costs in half compared with hospital outpatient clinics.

The COVID-19 pandemic and its subsequent social and economic effects have taken their toll on the mental well-being of our society. Data suggest that the incidence of mental health and substance use disorders is increasing. OptumRx analytics show that in March the number of prescriptions for anti-anxiety medications increased 15%; for antidepressants, 14%; and for sedative hypnotics, 5%.

Virtual services will continue to be a powerful support tool for those requiring more high-touch care, including patients with mental health, substance use disorders and other complex, chronic health conditions. OptumRx has leveraged its Genoa Healthcare footprint to provide support through telepsychiatry, our Optum Emotional Health line, virtual visits and complimentary, on-demand emotional support via the Sanvello mobile app.

In this new healthcare environment, pharmacy benefit managers are uniquely positioned to help protect continuity of care, given the vast and diverse resources at our disposal. Our collective goal should be to build upon what we have learned during this time. We should continue to deploy and refine tools that will yield positive clinical and financial value while also improving care and service in a post-pandemic environment.

David Calabrese, RPh, M.H.P., is senior vice president and chief pharmacy officer for Optum Rx and a member of the Managed Healthcare Executive® Editorial Advisory Board.

Articles

Senior Vice President and Chief Pharmacy Officer for Optum Rx and member of the Managed Healthcare Executive® Editorial Advisory Board, David Calabrese, provides his commentary on the future of pharmacy care services after the coronavirus pandemic.

Opinion: The Future of Pharmacy Care Services, Post-Pandemic

Digital transformation in the healthcare industry has tremendous potential to change the way we approach patient care and to enhance the overall quality of care. This shift is particularly important in pharmacy, which is poised for digital innovation but is far-less advanced compared to other industries due to perceived barriers to adoption. Even in today’s digital era, many pharmacists still rely on handwritten prescriptions to provide patients with the medications they need.

Electronic prescribing, or e-prescribing, is one emerging innovation with great potential to mitigate the issues associated with hard copy prescriptions, such as forgery and fraud; illegible scripts leading to inaccurate fills, 

; and decreased administrative efficiencies. By enabling care providers to send accurate, easy-to-read prescriptions directly from the point-of-care, patients realize significant short- and long-term benefits.

One of these benefits is greater adherence. According to 

e-prescribing is associated with a significant decrease in primary nonadherence among patients. In addition, e-prescribing helps improve patient-provider dialogue, reduces costs through a wider selection of formulary and generic alternatives, and gives providers immediate access to a patient’s formulary, drug history, and prescription benefits for decision support – increasing accuracy, efficiency, and safety across the board.

A major opportunity for improvement is reducing prescription errors, and e-prescribing has proven to reduce the likelihood. When using hard copy scripts, the barrier of interpretation can contribute to inaccurate fills. This occurs when a pharmacist incorrectly interprets the physician's handwriting and inadvertently supplies the patient with the wrong drug, dose or quantity, which can adversely impact a patient’s health.

How 2018 Pharmacy Trends Are Affecting 2019

A digitally received script removes the need for interpretation and drives a higher level of clinical accuracy and integrity. 

 that error rates have decreased from 42.5 per 100 prescriptions to 6.6 per 100 prescriptions (nearly a seventh of the previous level) in just one year after the adoption of e-prescribing.

With current e-prescribing systems, providers receive eligibility, formulary, and medication history in real time, providing visibility to lower-cost alternatives that can enhance overall cost effectiveness for patients.

As an added convenience, prescriptions can also be automatically sent to the patient’s pharmacy of choice. This eliminates the need for patients to physically bring a prescription to the pharmacy, drop it off, leave, and come back to pick up their medication. This also saves patients time, which can translate into dollars for people who don’t have to take time away from work to manage their prescriptions.

Finally, the positive impact of e-prescribing on patient safety cannot be understated. In addition to reducing the risk of an inaccurately dispensed drug or dose, e-prescribing gives physicians access to a patient’s prescription drug history at the point of prescribing. When physicians have access to this information, they can appropriately prescribe dose increases or add another concomitant medication to ensure positive therapeutic outcomes are achieved (e.g., blood pressure; HbA1c; cholesterol levels). 

E-prescribing can also play an important role in managing controlled medications, such as opioids. Access to a patient’s prescription drug history can help mitigate fraud and plays an important role in addressing our nationwide crisis of drug overdose and death. Legislation has been introduced in the Senate that would require healthcare providers to employ e-prescribing for all opioids and other controlled substances for Medicare Part D recipients beginning in 2021, 

 (healthcare management consultants in Jacksonville, Florida). Several states already have similar legislation in place for all controlled prescribing, and others have legislation pending. E-prescribing, especially when combined with other healthcare services such as home delivery, results in better accuracy, reduction in error, and the prevention of abuse, fraud, or manipulation.

As adoption rates rise and the industry progresses toward mandated e-prescribing, physicians will be required to use the initial e-prescribing interface. This will further increase the quality and cost-efficiency of care for patients and minimize administrative burden for the provider and patient.

This transition has accelerated development of more comprehensive digital tools, including OptumRx’s PreCheck MyScript, which enhances the e-prescribing process by providing real-time, patient-specific benefit information at the point-of-care. As a result, members can see improved health outcomes, improved access to therapy, and significantly lower out-of-pocket costs.

Four Reasons Payers Are Investing in Real-Time Benefit Check

With progress toward the universal adoption of e-prescribing, our nation’s pharmacy care landscape will see increased efficiency of the prescribing process and lowering of incurred costs for all involved. From clients and members to physicians and pharmacies, e-prescribing promises better coordination of care and communication across the healthcare continuum.

David Calabrese, RPh, MHP, is senior vice president and chief pharmacy officer of OptumRx. He also is an editorial advisor for

How the digitalization of pharmacy is transforming patient care.

3 Benefits of E-Prescribing

In reviewing the healthcare industry’s most impactful innovations, advancements and shortcomings over the past year, several focus areas emerged that were, and will continue to be, important in the years ahead.

While it was a busy year for specialty pharmacy overall, perhaps no area was more active than oncology. In addition to a 

 for breast cancer, the FDA approved several new drugs based on a concept called 

. The idea is simple enough: train the body’s own immune system to identify and kill cancer cells.

However, the enthusiasm surrounding immunotherapy must be balanced against the considerable safety and cost issues that the therapy entails. While immunotherapy is currently targeted for a narrow range of cancers, the hope is it will soon be approved for broader indications.

Much as immunotherapy offers new options for treating certain types of cancer, a new class of migraine medications entered the market in 2018. Known as 

, these long-lasting drugs are antibodies that target the physiologic processes underlying migraine.

While CGRP antagonists appear promising, they do come at a substantial cost. Moreover, it has not yet been established that they are any better in terms of efficacy or safety than other currently available therapeutic options from other drug classes. Accordingly, OptumRx has a 

Making sense of drug pricing complexities

The issue of prescription drug pricing has long been a matter of debate. Yet, in 2018, the issue became even more high profile as the White House, regulatory bodies, and Congress all issued public proclamations on the issue of drug costs.

The current model isn’t going away completely any time soon, but change is coming, and one of those primary shifts will be the evolution of value-based contracting. Pharmacy care services companies must proactively engage in value-based agreements with pharmaceutical companies and work to develop broader-based applications of the value-based concept to bring to clients and lead the market, as opposed to follow it. 

Provider Engagement in the New Digital Era

Speaking of expensive medications, 2018 gave us a glimpse into a future where the price of certain drugs eclipses $1 million.

. Working at the genetic level, they offer us entirely new avenues to treat disease. Recent introductions have included two CAR T gene therapies for the treatment of select forms of cancer and a third agent to treat patients with an inherited form of vision loss that may result in blindness.

With over 400 gene-based therapies in either phase 2 or phase 3 clinical development, significant attention will continue to be drawn to this area as changes in policy, pricing, education, treatment, and accessibility evolve.

In 2018, there was real progress in collective efforts to turn back the tide of the opioid epidemic as new preventative and treatment programs were introduced to the market.

OptumRx notably achieved compelling results from its Opioid Risk Management program, a comprehensive framework created to reduce opioid misuse and abuse. Centered around the deployment of five interrelated strategies-prevention and education, minimizing early exposure, reducing inappropriate supply, treating at-risk and high-risk populations, and supporting those in recovery-the program has achieved a 31% reduction in opioid prescriptions, as well as a 42% decrease in the total opioid morphine milligram equivalent (MMEs) dispensed, since its inception.

Nationwide, increased access to care and clinical support has resulted in a 

 As solutions become more readily available, pharmacy care services companies will have a unique opportunity to directly deploy these programs and help those suffering from opioid addiction and dependence. 

Last year brought a variety of new treatments-and complications-for patients and payers. These five areas that defined 2018 will continue to define the future.

Taking the life of a U.S. citizen every 13 minutes, the opioid epidemic continues to devastate our country and overwhelm our communities, neighbors, coworkers, friends, and family members. This national health crisis places an undue burden on the entire healthcare system, negatively impacting health outcomes and causing significant financial strain.

While it’s well-documented that these medications remain overprescribed, opioids represent very effective options for managing pain for select chronic medical conditions like cancer and end-of-life care, and in short-term treatment of more severe acute pain where alternative therapy may not be suitable. Despite the attention drawn to the epidemic and the excess supply of these medications on the market today, we must also remain conscientious of the large numbers of patients with chronic, debilitating pain who rely on opioids to improve their quality of life and overall function, and ensure appropriate access to viable, effective, non-opioid treatment alternatives.

Opioids are powerful medications with highly addictive potential, and anyone taking them, regardless of predisposition to addiction, can find themselves struggling with reliance and dependence. An estimated 2.1 million Americans suffer from ‘documented’ opioid use disorder, according to the Substance Abuse and Mental Health Services Administration. Further, data shows the 

, including treatment, was $504 billion in 2015.

Given the depth and breadth of this crisis, virtually all constituents of the healthcare system hold some level of responsibility in utilizing tools and resources at their disposal to help address this epidemic. To be successful, solutions must be multidimensional, mixing evidence-based clinical programming, educational outreach, and aggressive intervention in order to curb overuse, misuse and abuse, and to protect the safety of those requiring opioid therapy. Efforts must address every step of the process and target all stakeholders including patients, pharmacists/pharmacies and physicians. The most effective actions will address the contributing factors at the epidemic’s core, with tactics spanning several components, such as:

. Despite the prevalence of this issue, many don’t realize how closely tied this problem is to an inclination to overprescribe, over-demand and over-consume opioid medications. Appropriate use of opioids is achieved when pharmacists, physicians, caregivers and patients are fully informed about the risks, proper dosage, drug storage, and potential side effects.

. Since features of physical dependency can begin to occur within as little as a few days of initiating opioid therapy, safer non-opioid alternatives should always be considered for treating chronic and acute pain. When opioids are used, physicians and other healthcare providers who prescribe these medications should do so consistent with CDC guidelines for both dosing and length of therapy.

. Despite growing concerns regarding the epidemic, physicians and other healthcare providers

 issued nearly 215 million opioid prescriptions 

equating to nearly one full 30-day supply for every adult U.S. citizen

. By reducing the initial supply of opioids in patients newly exposed to an opioid to an acceptable amount based on a patient’s condition, physicians and prescribers can better monitor usage, and patients are less likely to abuse treatment. Applying evidence-based utilization management protocols, limiting unnecessary therapy extension, monitoring for abuse and diversion, and decreasing exposure to harmful drug interactions through routine medication screenings can help limit the inappropriate volume of opioids prescribed.

Four Ways Health Execs Can Help Patients Recover from Addiction

. Certain patients are at a higher risk for opioid dependency/misuse based on daily dosage, drug combinations, doctor or pharmacy shopping, and/or previous history of substance abuse issues. Progression to chronic opioid use, defined as regular use with signs of dependency, can be averted by developing programs that prevent fraudulent dispensing, as well as adopting prescription monitoring and auditing programs that use data to find at-risk patients in real-time. For members at the highest levels of risk for opioid abuse and overdose, intensive, personalized management by fully informed care professionals may be required.

Supporting chronic populations and recovery

. Identifying and guiding patients with current or previous histories of overdose or misuse are critical long-terms solutions to the epidemic. Effective treatment options such as the proactive promotion of medication-assisted therapy (MAT), monitoring adherence to such therapy, monitoring for patient relapse, and offering long-term support are proven strategies in improving healthcare outcomes.

Safe disposal of excess supply after treatment

. According to national study, approximately 

 retain leftover opioid medications in the home, often in unsecured locations. Additional data supports the fact that many of those who misuse, abuse and divert opioid medications are commonly obtaining them by borrowing, stealing or buying leftover opioids from friends, family, or other acquaintances. Rather than disposing of unused opioids in the trash where they can be retrieved and potentially abused, or flushing excess pills which can contaminate water supply, a safe, convenient, and effective method of disposal should be used such as a Deterra kit. The 

 kit is a simple-to-use means of deactivating the opioid medication so it can be properly disposed of and not misused. Organized collections like 

 also represent an opportunity for safe drug disposal.

As a pharmacy care services company, OptumRx is focused on improving health outcomes and lowering total healthcare costs. Through implementing tools such as advanced data analytics, prior authorization requirements, and fraud monitoring strategies, OptumRx has achieved a significant degree of success through its 

. For example, health plans and employer clients who have adopted the program saw significant reductions in opioid prescriptions and average daily opioid dosing, facilitating greater compliance by physicians and other prescribers with opioid prescribing standards set by the CDC. Positive results since the program’s launch include a 31% reduction in opioids prescribed, and a 34% reduction in total doses dispensed. Most importantly, in a recent analysis conducted by OptumRx and Optum Labs, clients who deployed such programming witnessed a 50% lower likelihood of patients progressing from short-term acute use to longer-term chronic opioid use.

As an industry and a country, we’re collectively taking steps in the right direction and the results we’ve seen have been encouraging. The current administration has passed 

 that would help reduce the supply of highly addictive substances, like fentanyl, while creating incentives for using non-opioid pain treatments to improve quality of outcomes. A recent 

from the American Medical Association shows the number of opioid prescriptions decreased by more than 22% between 2013 and 2017, with a 9% decrease between 2016 and 2017 alone.

While progress continues to be made, ending the opioid epidemic is a process, and will require collaborative action amongst multiple stakeholders across the health care continuum and beyond-including care providers, pharmacists, governments, clients, individual consumers, and community organizations-with the ultimate goal of protecting our citizens, while still preserving the highest quality in health outcomes for all.

David Calabrese, RPh, MHP, is senior vice president and chief pharmacy officer of OptumRx. He also is an editorial advisor for Managed Healthcare Executive.

Healthcare stakeholders can impact a patient’s health by leveraging available capabilities and resources to help achieve better health outcomes and address this opioid epidemic.

Six Ways to Effectively Manage Pain During an Opioid Epidemic

The way we practice medicine in the U.S. has evolved significantly over the last 20 years. What began as a largely entrepreneurial, small-group practice model where providers used paper charts and forged lifelong relationships with their patients, has transformed into large-scale health systems that favor IT infrastructure, data and analytics, and capacity. The result? A complex, still largely disjointed system where providers-and patients-are sometimes left behind as it relates to sufficient communication, coordination, and education/engagement.

Provider engagement, in particular, is more important than ever to ensure better outcomes and greater value throughout the healthcare system. Engagement requires heightened transparency and easing the administrative burden of physicians. 

I recently sat down with Bradford Curtis, MD, FAAP, vice president and senior medical director at OptumRx, to talk about his insights and observations, as well as where he sees the future of provider engagement headed.

Calabrese: What have the greatest struggles for providers traditionally been?

: The practice of medicine, whether in a primary care physician’s office or a tertiary care center, has always been about improving patient health. Rather recently, the delivery of healthcare has been reevaluated in terms of outcomes, and the focus now encompasses four key objectives:

Improving the work lives of healthcare providers.

Meeting each of these objectives is quite complex and has hindered the rate of digital transformation in healthcare in comparison to other industries.

Providers have experienced a tremendous increase in administrative burden as the number of pilot programs and initiatives attempting to solve for the “value” equation outpaced the technological infrastructure and operational systems to support the vast array of these efforts in an orderly, manageable manner.

Inefficient processes and systems with inadequate interoperability and static data capture hampered the full potential of data analytics, as integrated health systems attempted to meet new requirements from payers and regulatory and accreditation bodies, each of whom have a different agenda. One result was providers spending a significant amount of time entering data into an EHR system rather than directly engaging with patients in a more personal way that many would prefer, or that makes them feel valued. As a result, to meet the requirements imposed upon them, providers are now either seeing fewer patients per day, spending longer hours in the office to complete their administrative tasks or having to use scribes to enter data into the EHR systems, negatively impacting their professional satisfaction, quality of life, and practice overhead.

Calabrese: How have recent advances in digital technology enhanced providers’ abilities to engage with patients?

: Recent point-of-care innovations are allowing providers to engage with patients in new ways and better fulfill modern healthcare’s four primary objectives.

Technology is providing greater transparency than ever before. For example, providers can receive notifications about medication gaps-in-care and low medication adherence, allowing them to intervene before a patient suffers an adverse consequence. Electronic systems can support decision making around drug selection based on member formularies, allowing providers to consider effectiveness alongside total drug cost, patient out-of-pocket cost, and prior authorization requirements. These systems also support electronic prior authorizations, significantly streamlining the prior authorization process and saving time for both providers and patients. This higher level of engagement is leading to happier patients with lower out-of-pocket costs, reducing rework switching prescriptions, increasing adherence rates, and reducing complications from diseases associated with non-adherence-fulfilling all four objectives.

Patient portals that allow online scheduling, new patient registration, benefit information including prescription drug formulary details, educational materials, and prescription refill information have helped drive patient engagement as well. Telehealth service adoption has been slower than originally anticipated due to a lack of broad and clearly defined use cases, physician confidence, connectivity, scheduling challenges, and reimbursement issues, but these issues are increasingly being solved for in pursuit of telehealth’s promise of lowering delivery cost and increasing access for those in remote settings or with transportation challenges.

Calabrese: What have been some of the greatest successes as a result of improved digital provider engagement?

: From a pharmacy-centric point of view, electronic prescribing and electronic prior authorization have been the industry’s greatest successes as a result of digital provider engagement. 

Electronic prescribing increases both clinical quality and efficiency by enabling providers to easily view a drug’s formulary status, reducing prescription fill errors, supporting rapid fills at the pharmacy before patient arrival, supporting efficient tracking of medication history and medication reconciliation, and supporting an efficient refill process. 

Similarly, electronic prior authorization facilitates an efficient prior authorization review process, with the ability for some decisions to be rendered electronically in real time, without the need for manual review. 

Calabrese: What trends do you anticipate for the future of digital provider engagement?

: There is an ongoing focus on enhancing existing tools that allow providers to weigh the merits of different medications at the point of prescribing, as well as improvements in the electronic prior authorization space.
Additionally, we already see real-time integration of both medical and pharmacy data, leveraging machine learning to suggest possible diagnoses and the next best action for treatment-this will continue to play a bigger role in healthcare as the industry becomes more synchronized.

Also on the radar is the continued and further level of adoption of risk-based payment agreements, in which providers collaborate to manage the cost and quality of care for a patient population. This type of payment model is a natural fit for integrated health systems that can bring to bear greater data analytics capabilities to drive better clinical outcomes and lower cost of care. Those who can combine these capabilities, along with strong office workflow management, will not only enhance clinical outcomes and cost of care, but also succeed in improving the quality of both the physician and patient experience.

David Calabrese, RPh, MHP, is senior vice president and chief pharmacy officer of OptumRx. He also is an editorial advisor for 

Bradford Curtis, MD, FAAP, vice president and senior medical director at OptumRx, talks with Managed Healthcare Executive Editorial Advisor David Calabrese, RPh, MHP, about the future of provider engagement.

One of the greatest healthcare issues we face in the United States is the cost of prescription medications. Too often, medications are priced at a point that places an undue financial burden on patients, who are left with few-or no-care alternatives, and on payers, who must find ways to continue to cover the rising costs of prescription drug coverage for their members.

Each year, the FDA approves an average of 40 to 50 new drug therapy products to enter the market, including a combination of traditional drug products, specialty agents, and more recently, several products for rare orphan diseases. As these products make their way to market, PBMs and managed health providers have developed a proven means of monitoring their entry and quickly evaluating their clinical merits to determine formulary placement and any required utilization management protocols.

However, what many may fail to realize is that beyond these 40 or 50 new molecular entities approved by the FDA each year, hundreds of other non-unique and often higher-cost prescription drug products also make their way to the market every week-some piggybacking off prior FDA approvals and some bypassing proper FDA-approval pathways altogether. These products include a range of what industry experts would consider ‘clinically superfluous’ brands, which offer little to no added clinical value over currently available therapeutic options, many of which are often available in generic or even over-the-counter (OTC) form.

It is often smaller, niche pharmaceutical companies contributing to this issue through routine launch and aggressive promotion of these smaller-market branded medications that offer little, if any, added diversification. These medications most frequently appear as costly reformulations of existing generic products; as “me-too” branded therapies that offer little incremental value over lower cost alternatives in the same drug class; and/or as repackaged versions of previously approved treatments lacking supporting clinical evidence, yet still citing claims of therapeutic benefit.

This national disparity has made headlines in past years. One recent example that shocked the nation is Vimovo, a nonsteroidal anti-inflammatory drug that skyrocketed to a wholesale price of $2,979 per bottle in 2018, 22 times more than it had cost in 2013. Vimovo is comprised of two highly accessible and inexpensive OTC medications-naproxen (Aleve) and esomeprazole (Nexium)-that can be independently purchased for a combined cost of approximately $36. Another is the pain reliever Duexis, a combination of two dated, although widely accepted generic products: ibuprofen (Advil/Motrin) and famotidine (Pepcid). If prescribed separately, the two drugs together cost no more than $10 to $20 a month. By contrast, Duexis, which contains both in a single pill, costs about $2,000 a month.

Another particularly alarming therapeutic area where the entry of high-cost, clinically superfluous products is rampant is topical pain medications and other dermatology products. Many of these drugs are categorized into what is known as “convenience kits.” These kits most often contain a combination of low-cost, off-patent creams, ointments and solutions, repackaged with other OTC supplies like bandages and cleansers, and then marketed to providers and billed to insurers and government programs as patented, brand-name prescription products. Examples of convenience kits include Dermacinrx Pak, a patch containing the 70+-year-old analgesic lidocaine (the same ingredient in the OTC product Aspercreme), along with an emollient cream, where an average prescription cost exceeds $5,500. Its alternatives, obtained separately, would cost a payer less than $200. The topical skin rash treatment Xilapak, which combines the several-decades-old steroid product fluocinolone (available generically via prescription) with an OTC cleanser (Cetaphil) and silicone tape has an average prescription cost exceeding $4,100. In this instance, the generic components obtained separately via prescription (generic fluocinolone solution) and OTC (cleanser and tape) would cost a payer just over more than $100.

Me-Too and Non-Essential Drug Costs in Comparison to Alternative Medications*

*Average ingredient costs based on OptumRx commercial book-of-business data, Q1 2017

PBMs are uniquely positioned to remedy this issue because they sit at the intersection of drug manufacturers, pharmacies, and healthcare providers. PBMs touch nearly every part of the health system and are on the frontlines of the drug price debate. In the interest of clinical and fiduciary accountability, these organizations have a key responsibility to deploy proactive, comprehensive monitoring and intervention strategies to keep drugs affordable and protect clients from undue financial exposure. PBMs that provide unimpeded coverage for these medications can be viewed as performing a major disservice to the clients and members they serve.  Such lax practices may be driven by administrative complacency or the promise of extensive rebate offerings by drug manufacturers; however, it must be noted that such rebates will not offset the vast cost differential between these superfluous brands and their generic and OTC alternatives.

Advancements in new drug surveillance activity and the deployment of more proactive drug benefit, and formulary exclusions are critical tools that every PBM should leverage to protect clients and patients from unnecessary healthcare costs.

At OptumRx, a Clinical Affairs team has developed what it refers to as its Vigilant Drug Program to accomplish this objective. This voluntary program consists of weekly lists of new products entering the market that OptumRx has carefully vetted, with oversight from an independent Pharmacy and Therapeutics Committee, to identify superfluous drugs. These lists are currently comprised of hundreds of unique national drug codes (NDCs), like the ones previously described. For clients adopting this program, these “me-too” drugs are immediately restricted from coverage at the outset of their introduction to market, protecting clients and members from financial burden, potential safety risks and future formulary disruption.

Today, a large majority of OptumRx’s client base has adopted this program as another key means of managing the rising cost of prescription drugs. On average, the deployment of the Vigilant Drug Program has saved clients an average of 2% to 4% on overall drug spend. OptumRx is expanding the program with new lists that clients can choose from to protect against other market dynamics that place upward pressures on drug trend, including high-priced generics with equally safe and effective lower-cost alternatives; branded prescription drugs with widely available OTC equivalents; and multisource brands with interchangeable prescription generics.

Though the number of product exclusions from formularies has grown at a rate of about 15% to 20% per quarter in just two years, many of these aforementioned products are not necessarily being included in these exclusion lists. Additionally, it is highly unlikely that pharmaceutical companies who have benefited from them will halt the production of these clinically exorbitant drugs or the aggressive marketing tactics that go with them. As such, PBMs can, and must, provide a necessary counterweight to these activities by implementing programs that ensure a formulary offering that delivers the greatest possible health outcomes at the lowest cost to both clients and members. Such programming, when effectively developed, not only holds manufacturers accountable, but helps to set a consistent industry standard for effective drug monitoring and prescription cost trend management.

David Calabrese, RPh, MHP, is senior vice president and chief pharmacy officer of 

PBMs are in a unique position to leverage three critical tools to protect patients from unnecessary healthcare costs.