A New Deal with Managed Care - Pharmaceutical Executive


A New Deal with Managed Care
A PE Roundtable

Pharmaceutical Executive

Some pharma companies have begun detailing employers to promote the need for their product on formulary. But hiccups along that road, such as who in employers' human resources offices is responsible for reviewing that data, have stunted those efforts.

"One challenge is to understand how employers will or will not accept us," says Zak. "Over the last five years, there has been a huge shift in employers' receptivity to being detailed. Employers now want us back in the door to give them new information about breakthrough therapeutics. The challenge is that there are so many of them out there that and they tend to accept and trust MCOs a lot more than they trust us. We're trying to understand how to get to them with the information that they want in the most efficient way, but it's not easy."

Working Together Although the different aspects of pharmaceuticals-selling, prescribing, taking, or managing their cost-point to different missions, there are areas in which stakeholders can be partners. "This bumpy journey defining value starts with a collaborative and transparent approach with all stakeholders," says Bailey. "Good, quality healthcare actually can reduce costs. And at the end of the day, everybody can rally around that."

One key to good health-for patients, MCOs', and industry's bottom lines-is to ensure that patients take their medications as prescribed. Zak says, "The one common goal is persistency and compliance, because if the patient doesn't continue on the drug, we all lose. Our drug isn't as effective, the payer loses out because they have been paying the money for a long period of time but they don't get the end result that our package insert states. Then the practitioner ends up losing, because the patient isn't being treated."

Lynn Nagorski, national field manager for managed care at Purdue Pharma, notes, "We've talked about the physician's role, the patient's role, and the employer's role. But the nurse's role will play a bigger part in ensuring compliance."

Wertheimer agrees. "Whatever the condition, the lack of compliance ends up costing MCOs a fortune because they will have to pay, probably with a lengthy hospital visit. And compliance seems to be such a simple, definable problem. But for whatever reason, no one chooses to go after it as a horrendous, solvable problem even though the strategies that are known to be effective are not that terribly expensive."

It is realistic to expect that managed care's quarterly newsletters and industry's e-mail medication reminders have done little to promote persistence and compliance. "We don't do a good job of educating patients about how important it is for them to take their medicine," says Avey. "If we don't solve the compliance issue now, there's going to be trouble later on when there are more expensive drugs."

Both industry and payers may turn up the spotlight on pharmacists to drive appropriate patient behavior. Steven Friedman, RPh, president of Pharmacy First/Wholesale Alliance, which assists in developing patient medication compliance and persistency programs at the pharmacy level, asks, "How does industry maximize utilization to keep the patients on the drug that the companies work so hard to get on the formulary, to get the physician to write it, and to get the pharmacist to dispense? That is a core issue that is an opportunity for the industry as a whole. In my opinion, pharmacists are not being used properly in today's environment. They are focusing on the mechanical aspects of taking pills and putting them in the bottles as opposed to providing healthcare to patients, keeping them on their drugs, keeping them compliant."

Another area of partnership is unbranded disease education. Sitton recalls, "Physicians took the lead back in the early 1990s and said, 'It is important to warn patients about heart disease. We need to ask what their cholesterol number is.' And then patients started asking, 'What's my number?' Then statin sales increased. We must now ask, 'What can we do with diabetes?' We all should throw our chips in the game and say, 'Give consumers better diabetes education so they can get healthier.'"

But perhaps disease management programs between private companies and the states offer the most hope for big-picture change. Indeed, it is likely that companies will continue to take those public health roles if partnerships are as effective as the one Pfizer developed with the Florida Agency for Health Care Administration. The company recently reported that its two-year trial program to deliver $33 million in Medicaid savings, in exchange for listing the company's products on the state's preferred drug list, is on track. "I'm very encouraged, both from the public and the private side of things," says Bailey. "Numerous examples have gotten some air time over the last year or two-with Pfizer in Florida and Lilly's programs in Arkansas and Colorado."

Those partnerships are particularly effective because they "align the incentives" between companies and payers and generate efficiencies, integration, and communication. That may offer a stopgap to the growing rumblings pushing for a single-payer system, such as the proposal put forth by Physicians for a National Health Program in the August 13 issue of the Journal of the American Medical Association.

Says Wertheimer, "We all hear the stories about why do something for a patient when they'll be someone else's problem five years from now? The only way to arrive at high-level wellness with screening and optimal patient education is to have the people invest in it today for a benefit in the future. That requires one payer."

Levine notes that a national healthcare system is the answer-but only if today's stakeholders fail to make the market-based system work. "If we can undertake a responsible approach so that we optimize all of the pieces in the system, we have an opportunity to make the market work. When we look around the world, we don't see any single-payer systems that are working terribly well. We've had a lot of experience with the national health system over the last few years, and there are many parts of that that do work, but there are many parts that are broken. And they are looking to the United States for models on how to improve their single-payer systems. But if we fail to behave responsibly over the next decade, it will default to that."


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