The road to managing high cost prescription drug therapies can be bumpy and riddled with obstacles but often there are advanced solutions available that are not always widely used. Several drug utilization management tools can be strategically implemented to provide more cost effective and therapeutically appropriate treatment options for injured workers. Two such tools, step therapy and therapeutic interchange, are advanced medication management protocols designed to improve overall patient care and outcomes. These pharmacy benefit management components have achieved proven results and provide valuable opportunities for payers to facilitate access to high quality health care that is both economically balanced and appropriate.
A number of prescription and over-the-counter drug therapies offer similar therapeutic benefits but with widely varying costs. “Step therapy uses evidence-based treatment guidelines to ensure that patients receive the most appropriate, cost-effective treatment regimen for a medical condition,” noted Silvia Sacalis, PharmD, a clinical pharmacist and vice president of Clinical Services at workers’ compensation PBM Healthesystems. “The program utilizes a step-wise approach to guide physicians towards prescribing lower cost, yet effective and safe alternative drugs as a first step. In cases where the patient does not positively respond to the initial therapy, physicians can subsequently prescribe other options as needed.”
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) – Celebrex® is a good example of a drug that can be more effectively managed through step therapy. While this higher priced NSAID may be associated with fewer incidences of stomach ulcers that can occur from long-term NSAID use, Celebrex should be reserved for patients with a history of gastrointestinal complications and those who have not benefited from or tolerated traditional NSAID therapy. Traditional NSAIDS such as Motrin®, Mobic® and Aleve® offer comparable therapeutic pain-relieving benefits at a significantly lower cost and should be initially used for patients who are at low or no risk for gastrointestinal complications. In cases where patients have an increased risk for GI adverse events, combination therapy with a traditional nonselective NSAID and an over-the-counter (OTC) proton pump inhibitor such as Prilosec OTC®, provides gastro protection that is superior to using an NSAID alone.
A step therapy program focused on Celebrex would prospectively identify this drug prior to being dispensed and determine if it already exists in a patient’s drug utilization history or whether it is the most appropriate initial therapy choice. For patients that have no previous history of traditional NSAID use or gastrointestinal risks, an alternative less costly but equally effective traditional NSAID therapy would be suggested to the prescriber.
Jurisdictional rules must be considered prior to implementing these additional protocols, but when appropriately applied, the benefits and results are proven. For example, Healthesystems clients achieved an average savings of over 70 percent when step therapy protocols specific to Celebrex were applied due to the prescriptions being changed to the suggested therapeutic alternative.
As more drugs become available within individual therapeutic drug classes, there is often a large cost disparity among medications. Therapeutic interchange involves the substitution of a lower cost drug with a different chemical composition that is therapeutically similar to the more expensive medication initially prescribed. “Therapeutic interchange is another tool that can be used in concert with formulary management, evidence-based guidelines and care management protocols to assist payers with managing pharmacy costs,” explained Dr. Sacalis.
The goal of therapeutic interchange is to enhance the quality of care and overall outcomes at a reduced total cost. Criteria used in the selection of medications for therapeutic interchange should be based on the availability, therapeutic and cost differences of the drugs.
Patient monitoring following therapeutic interchange is important to determine whether the medication achieves the desired therapeutic result. Patients who experience side effects or an inappropriate response from the recommended alternative medication should be re-evaluated.
Proton Pump Inhibitors (PPIs) – PPIs benefit patients with gastroesophageal reflux disease (GERD) or who are taking NSAIDs by protecting against NSAID-induced stomach upset. A wide range of prescription and over-the-counter (OTC) PPI formulations are available such as Prilosec®, Prevacid® and Nexium®.
Prescription Nexium® was the number two drug prescribed in the U.S. in 2013, even though all PPIs provide a similar clinical benefit. Given the widespread use of prescription PPIs, therapeutic interchange can better monitor and manage the cost of this highly utilized class of medications. The spring 2014 issue of Healthesystems’ RxInformer clinical journal includes an article, “Step Therapy and Therapeutic Interchange,” which contains PPI cost comparisons and more detailed information on these cost-saving strategies.
Effective use of more strategic pharmacy benefit management tools such as step therapy and therapeutic interchange can minimize overall costs, improve patient access to more affordable medications and provide an improved quality of life. Implementing these strategies requires a thoughtful and collaborative partnership between the payer and PBM and will ensure that patients receive the highest quality of care balanced with the necessary cost controls.
About Silvia Sacalis, PharmD
Silvia Sacalis, PharmD, is a clinical pharmacist and vice president of Clinical Services at Healthesystems, a leading PBM and ancillary medical benefits manager serving the workers’ compensation industry. Her experience and clinical expertise span the PBM, retail pharmacy and managed care environments. Leveraging her technology background, clinical skills and management expertise, she helps develop and operationalize strategic clinical initiatives to help workers’ compensation insurance payers maximize the impact of a pharmacy benefit management program. Throughout her career, she has held various leadership roles in which she provided oversight of the development of clinical services programs, and integration of analytics technology with clinical consultative support. Dr. Sacalis received her Bachelor of Science in Computer Science and Doctorate of Pharmacy degrees from the University of Illinois at Chicago.
This is a sponsored post from WorkCompWire marketing partner Healthesystems.