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UKCMC MANAGED CARE PHARMACY WORK GROUP RECOMMENDATIONS Approved by the UK College of Pharmacy Executive Committee. 9/18/01 Edition. Current Issues. Therapeutic medication breakthroughs continue Rapidly escalating drug costs/expenditures

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9 18 01 edition

UKCMCMANAGED CARE PHARMACY WORK GROUP RECOMMENDATIONSApproved by the UK College of Pharmacy Executive Committee

9/18/01 Edition

Current issues
Current Issues

  • Therapeutic medication breakthroughs continue

  • Rapidly escalating drug costs/expenditures

    • 15-20% per year, Kentucky rate one of the highest in the US

    • UKHMO was 19.7% in FY01

      • PMPY Plan Cost went from $296.75 (99-00) to $355.21 (00-01)

    • Expected to double in 5 years

  • Greater societal dependence on drug therapy for treatment and prevention of disease

  • Promotion of high cost drugs by pharmaceutical manufacturers

  • Rising health insurance premiums and co-payments for pharmaceuticals

  • Employee dissatisfaction with costs and perceived benefit reduction

  • Inattention to the problem by practitioners and lack of involvement in addressing these issues

Utilization increasing another slice of the data
Utilization Increasing Another Slice of the Data

Managed care pharmacy work group
Managed Care Pharmacy Work Group

  • Problem StatementWhat recommendation or information can the UK College of Pharmacy and faculty provide to assist in maximizing medication effectiveness and economic efficiency?

  • Goals

    • Reduce rate of escalating drug cost trends

    • Reduce impact of drug costs on co-payments and premiums in FY03

    • Establish and educate individuals in controlling cost / quality of care (long term)

    • Incorporate cost effective utilization of pharmaceuticals into future role of College of Pharmacy

    • Promote the “Best Practice” in pharmacotherapy and pharmacoeconomics

In which aspects can the college of pharmacy contribute
In Which Aspects Can the College of Pharmacy Contribute?

  • Expertise in drug therapy, consultation on coverage

  • Pharma-Copay-Therapy Clinic - collaborative effort with medical staff

  • Programs and research projects targeted to reduce managed care expenses

  • Educational tools (computer support, dedicated time)

  • Conduct C.E. programs to target UK Physicians and UK-HMO

  • Development of a data warehouse to support best practice in drug use, treatment options/guidelines

  • Medication use strategies, creation of a Medication Use Management Center

  • Potential to contract with UK-HMO in risk-sharing agreement for cost-reduction

  • Commitment and dedication to the project

  • Integrate cost-effective therapy as an active part of College mission/curriculum and pharmacist’s role

Outline for presentation of a plan
Outline for Presentation of a Plan

College of Pharmacy



Cost Sharing


Preventive Service


Medication Use


Consumer Advertising


Academic Detailing


Drug Sample


Which options should be pursued? What are the next steps?

Health plan coverage of pharmaceuticals
Health Plan Coverage of Pharmaceuticals

  • UK has opted to utilize the co-payment coverage option for pharmaceutical benefits in the UK-HMO and PPO products.



No Coverage



Uk hmo prescription co payment coverage options
UK-HMO Prescription Co-Payment Coverage Options


Generic, Preferred, Non-Preferred; Few Non-Covered Diagnosis

Flat Rate

Not Recommended




Generic, Preferred,

Non-Preferred; Non-

Covered Dx


Non- Formulary

Sliding Percentage Rate

(Or mix with Tiered)

Uk hmo prescription co payment current coverage option
UK-HMO Prescription Co-PaymentCurrent Coverage Option

This is our current structure, however there

are options that remain that lead to escalating

prescription drug costs:

1. Should the non-preferred

drugs be discouraged

by a larger differential

in costs?

2. Are too many drugs


3. Are generic drugs promoted?

4. The co-payments have been adjusted to $8, $20 and $40.

Can we drive drug therapy to the lower co-pay drugs

(generic and preferred)?


Generic, Preferred, Non-Preferred; FewNon-Covered Diagnosis



Uk hmo prescription co payment recommended coverage option
UK-HMO Prescription Co-PaymentRecommended Coverage Option

  • This strategy could result in lower overall drug costs.

  • More drugs could be moved to a non-formulary status.

  • Change the Certificate of

  • Coverage to add a

  • non-formulary status.

  • 2. Will the system be

  • responsive to

  • changes?

  • 3. Is support present

  • throughout the

  • enterprise?

  • 4. Is medical staff willing

  • to make adaptations?




Generic, Preferred,

Non-Preferred; Non-

Covered Dx



Uk hmo prescription co payment alternative coverage option
UK-HMO Prescription Co-PaymentAlternative Coverage Option

This strategy could result in lower overall drug costs.

Some managed care plans are experimenting with this option.

1. Generally perceived as a reduction in benefits.

2. An example would be 10% for generic,

25% for brand and

50% for non-preferred with caps for each type.

3. Not recommended at this time.



Sliding Percentage Rate

(Or mix with Tiered)

Medication use strategies1
Medication Use Strategies

  • Review therapeutic drug groups with specific activities targeted to that group

  • Focus on high cost drug categories

  • Use Proton Pump Inhibitors (PPIs) as a pilot for program

  • Evaluate potential for Selective Serotonin Reuptake Inhibitors (SSRIs) or lipotropic agents (“Statins”)

  • Develop a structure/strategy accepted within the UKCMC enterprise

  • Program must be approved by the UK Managed Care Committee and Clinical Board prior to implementation

Ukhmo where are the drug costs rising
UKHMO Where are the drug costs rising?

Medication use strategies3
Medication Use Strategies

  • Proton Pump Inhibitor (PPI) Program Example

    • Dosing: Should dosing (QD versus BID) and utilization undergo closer scrutiny?

    • Duration: Should a three month plan limit be placed on PPI therapy?

    • Selection Change:

      • Should a step down to H-2 Antagonists (generic) be required for duration of therapy greater than 3 months?

      • Should antacids be advocated?

      • Should use of pantoprazole (Protonix) be required if a PPI is prescribed?

        • Effective July 1, pantoprazole is preferred but the others are available as non-preferred; should they be non-formulary?

    • Lifestyle Modification: Should these be promoted?

    • Educational components for prescribers and patients

    • Cost avoidance estimates can be projected if this option is to be pursued

Estimated ppi overuse 2001 dollars
Estimated PPI Overuse(2001 dollars)

Patients requiring PPIs >3 months

Patients requiring PPIs < 3 months

Estimated overuse of PPIs

Academic detailing solutions1
Academic Detailing Solutions

  • Formulary pocket guide

  • Counter-detailing teams

  • Targeted CE Programs

  • Provider feedback on utilization rates

Academic detailing solutions2
Academic Detailing Solutions

Formulary Pocket Guide


  • Develop global formulary guides (all plans)

  • Distribute printed pocket guides and PDA download version (via website access)

  • Target certain providers (i.e. residents)

  • Pro-active selection of the “plan drugs”


  • Ease and availability of web site update design / designer

Academic detailing solutions3
Academic Detailing Solutions

“Counter-Detailing” Teams


  • Assign team(s) of detailers according to therapeutic category

  • Team may consist of students, residents, faculty and pharmacists w/DI center assistance

  • Teams would develop detail pieces to inform providers of evidence-based practices and medication costs

  • Teams would plan regular times for face-to-face discussion with providers

  • Communication piece is left with the prescriber

  • Communication via email to providers or via web site

  • Points to be emphasized: Efficacy, Safety, Cost-effectiveness

  • CRITICAL SUCCESS FACTOR(S): Manpower and distribution of effort and targeting certain provider groups and drug classes first

Academic detailing solutions4
Academic Detailing Solutions

Internal CE Programs


  • Counter detail teams and CE office would develop programs

  • Programs would be given at grand round seminars, resident noon conference, etc.

  • Programs could be available on website

  • Target medical and pharmacy staffs

  • Expand training to Kroger pharmacists if applicable


  • Institutional support for programs

  • Manpower availability to create and provide programs

Academic detailing solutions5
Academic Detailing Solutions

Provider Feedback on Utilization Rate


  • Develop reports on prescriber utilization

  • Present by department (peer) and by individual prescriber to the medical staff

    • Create accountability of prescribing habits

  • Provide financial incentives for good utilization rates (tied to departmental or division performance)


  • Ensure accuracy of prescribing data

  • Physician buy-in of program

Drug sample solutions1
Drug Sample Solutions

  • Pharmacy Coordinated “Samples”

  • Generic “Samples”

  • Restrict Pharmaceutical Representative Access within Clinics

Drug sample solutions2
Drug Sample Solutions

Pharmacy Coordinated “Samples”


  • Central location for storing and distributing all samples

  • Pharmacist will dispense samples like regular prescriptions

  • Records can be kept about medication use by specific patients and prescribers

  • Patient education about new medication including co-pay information

  • Pharmacist may intervene before dispensing samples to ensure cost-effective utilization

  • Funding for pharmacy could be provided from pharmaceutical companies


  • Global institutional support

  • Space/location

  • Manpower for staffing

9 18 01 edition

Drug Sample Solutions

Generic “Samples” (UKHMO Funded Starter Prescriptions)


  • Provide some low-cost generic drugs as samples in the clinic (ex. ibuprofen, enalapril, metoprolol, amoxicillin, hydrochlorothiazide)

  • Samples provided through sample pharmacy with label

  • Up to a month supply

  • Incorporate access to these “samples” with counter-detailing pieces about generic utilization


  • Funding to provide starter prescriptions

Drug sample solutions3
Drug Sample Solutions

Restrict Pharmaceutical Representative Access within Clinics


  • Develop sign-in and sign-out policy

  • Utilize badge ID system

  • Set limits on time allowed in clinic during any given week or month

  • Set a policy for all industry sponsored lunches and events

  • Restrict or ban promotion of non-approved products including information and samples


  • Universal agreement to action and policy enforcement from Clinical Board

  • Alternative – control information and sample dissemination

Direct to consumer advertising jan to sept 2000
Direct to Consumer Advertising(Jan to Sept 2000)*

*Scott-Levin DTC Advertising Audit and Competitive Media Reporting, Third Quarter 2000

Consumer advertising solutions1
Consumer Advertising Solutions

  • Pharma-Copay-Therapy Clinic

  • Direct Patient Mailers

  • Update Website Information and Access

  • Kentucky Clinic Pharmacy Labels and Bag Stuffers

Consumer advertising solutions2
Consumer Advertising Solutions

Pharma- Copay-Therapy Clinic


  • Pharmacist clinic

    • Create a Kentucky Clinic Pharmacy Model

  • Help center for UKHMO patients to get advice on how to reduce out of pocket expense for drugs (and reduced Plan costs)

  • May be staffed by students, residents, faculty, and pharmacists

  • Set certain clinic days and make appointments

  • Expand to Kroger Pharmacies after a model is established


  • Institutional support

  • Clinic staffing and space

9 18 01 edition

Consumer Advertising Solutions

Direct Patient Mailers


  • Use the PBM system to “informally” identify patients

  • Send mailer about reducing out-of-pocket expenses by discussing with their provider the formulary alternatives

  • Target top 3-4 classes of drugs

  • Utilize advertising within KCP - Bag stuffer information dissemination

  • Develop other mailers to educate patients

    • Ask their providers if this medication is covered on insurance? What does generic mean? Can I ask for generic prescriptions from my provider? Why do drugs cost so much? How much is my insurance really paying?


  • Manpower to develop the information

  • Must stay within patient confidentiality guidelines

9 18 01 edition

Consumer Advertising Solutions

Update Website Information and Access


  • Include a “reduce your co-pay” section

    • Include an “ask the pharmacist” section

    • e-mail questions about medications or how to reduce monthly out-of-pocket expenses

    • DI center may be able to respond

  • Include the formulary guide and PDA download

  • Commonly asked drug questions (FAQs)

  • Add CE pieces

  • Place website access shortcut on alldesktops in clinic


  • Ease and availability of web site update design and designer

  • Must stay within patient confidentiality guidelines

Consumer advertising solutions3
Consumer Advertising Solutions

Kentucky Clinic Pharmacy Labels and Bag Stuffers


  • Include drug specific messaging – focus on wellness or disease of the month

  • Promote web site, include value added information

  • Identify drug costs on prescription bag

  • Expand to Kroger pharmacies after the model is established


  • Counter direct to consumer advertising

  • Utilize monthly contact to promote cost-effective drug use

Preventive service offerings1
Preventive Service Offerings

  • Partner with UK Wellness to integrate pharmaceutical information with Wellness information

  • Provide health service information upon dispensing

  • Pro-active long term solution

  • Example – Pharmacy coordinated smoking cessation program initiated in 2000

9 18 01 edition

Preventive Service Offerings

Identify Patient

Health Improvement

and Management Program / Clinic



  • Self managed

  • Lifestyle modifications

  • Education

  • Lifestyle modifications

  • Professionally managed

  • acute and chronic episodes of care

  • DSM, MD and RPh interventions

Program implementation timeline
Program Implementation Timeline

Provider Feedback on Utilization Rate

Intro of Non-Formulary Status

Begin Medication Use Strategies

Pharma-Copay-Therapy Clinic

Begin Targeted CE Programs

KCP Labels and Bag Stuffers

Restrict Pharm Sales Reps

Update Website Information

Preventive Service Offerings

Integration into Curriculum

Formulary Pocket Guide

Increase Website Access

Finalize Long-Term Plan

Drug Sample Pharmacy

Direct Patient Mailers

Counter Detailing Teams

Short-Term Plan

Generic Samples


1 - 3 months

3 - 6 months

6 - 12 months

Uk managed care pharmacy work group

John Armitstead, MS, RPh, Chair

Margaret Nowak-Rapp, PharmD

Bryan Yeager, PharmD

Robert Littrell, PharmD

Robert Kuhn, PharmD

Alan Zillich, PharmD

Eric Millheim, PharmD

Kelly Smith, PharmD

Julie Davis, PharmD (Resident)

Kim Mitchell, PharmD Student

UK Managed Care Pharmacy Work Group

  • Allen Woodward, MD (Advisory)

  • Ken Roberts, PhD (Advisory)

Approved by UK College of Pharmacy Executive Committee 7/12/01

Presented to UK Managed Care Committee 7/24/01

Presented to Chancellor Holsinger 8/13/01

The college of pharmacy contribution
The College of Pharmacy Contribution

College of Pharmacy



Cost Sharing


Preventive Service


Medication Use


Consumer Advertising


Academic Detailing


Drug Sample


Next steps
Next Steps?

  • Which of the recommendations are feasible?

  • Which actions require medical staff buy-in?

  • Which pharmacy staff members should be assigned to each recommendation?

  • Which recommendations can be implemented in Plan Year 2002, 2003?

  • Further review

    • UK Managed Care Committee in August for Budget Review

    • Clinical Board in September

    • UK Health Benefits Task Force in September