Short-cycle prescribing puts a lid on waste

Key Points

WITH MORE AND MORE COSTLY DRUGS breaking the bank for patients and payers, managed care organizations are developing programs to reduce a small niche of waste associated with early discontinuation of medication therapy. For example, a plan might reimburse for a full supply of a drug, which might be later discarded by a patient after only one dose. Managing this waste is an opportunity for added savings.

Express Scripts estimates such pharmacy-related waste will exceed $1.2 trillion between 2010 and 2014. Last year it exceeded $403 billion.

"Challenges such as side effects can result in a portion of medication going to waste," says Rhonda Letwin, RN, director, specialty reporting and analytics, Walgreen's Specialty Pharmacy.

"Patients new to these drugs often find the medication dosing and administration instructions to be complex," she says. "Because there is less physician oversight of self-administered oral chemotherapies compared with intravenous chemotherapies, there may be a delay before a physician is made aware of a patient experiencing medication side effects and resultant non-adherence."

Waste in specialty pharmacy is more apparent than for other drugs.

"If a patient throws away half of a $20,000 prescription that is not proving effective, it is noticeable," says Matt Totterdale, vice president of specialty pharmacy for Express Scripts.

He says stakeholders have to coordinate benefits across a spectrum of care, integrate information technology systems across sites and provide an "uber set of data," despite the variety of information generated by providers.

Express Scripts relies on its medical benefit management program, which combines utilization and reimbursement management for appropriate drug use. Traditional PBM tools help prevent issues, such as managing drugs under the medical benefit to identify waste along the continuum of care and establishing the most appropriate distribution channels, Totterdale says.

He says that the PBM might mail out only a portion of a 30-day prescription and hold the rest until pharmacists communicate with members about side effects and safety issues. After that, the balance of the prescription is sent to the patient.

"The idea is to blow all the waste out of the system, not just move it from one place to another," he says.

Walgreens Specialty Pharmacy created its Oral Oncology Cycle Management Program to support patients who take certain oral chemotherapy drugs. Pharmacists and oncology nurses contact patients at predetermined intervals during their first month of therapy to assess the patient's behaviors. Nurses educate them about potential side effects and confirm medication adherence.

If an adverse event is noted, the team responds according to established protocols and contacts the physician as necessary, Letwin says. The evaluation can lead to changes in medication therapy regimens or discontinuation of therapy without medication waste. At the conclusion of the first month of therapy, physicians receive a report that details the date the patient started and stopped therapy, adverse reactions or side effects and interventions performed on the patient's behalf.

The oral oncology drug program manages three medications-Nexavar (sorafenib), Sutent (sunitinib) and Tarceva (erlotinib)-chosen because of their high toxicity levels and high cost. Participants include all patients who are new to the therapies and receive the three drugs through one of Walgreens' central dispensing facilities. Letwin says the program will expand to include five other oncology drugs.

The latest results, collected over 31 months, translate to a potential of $2.1 million in savings if all patients had participated in the monitored dispensing option and improved rates of persistency with their therapy during the initial fills. The increase in persistency reflects the benefits of access to clinical support between physician office visits, Letwin says.

Regence Rx, a PBM based in Portland, Ore., contracts Walgreens as its preferred specialty pharmacy. Lynn Nishida, director, pharmacy services for Regence Rx, says its strategy helps to mitigate waste as pharmacists work with members and their physicians to dispense smaller quantities if appropriate.

"We avoid disincentives for [the lower quantity] supply by charging only a portion of the copayment," Nishida says.

The PBM also calls members instead of automatically refilling and sending a prescription.