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.

David Calabrese, RPh, MHP

Articles

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

3 Benefits of E-Prescribing

How 2018 Pharmacy Trends Are Affecting 2019

Six Ways to Effectively Manage Pain During an Opioid Epidemic