The adherence impact of a program offering specialty pharmacy services to patients using retail pharmacies.

BACKGROUND: A new service model integrates the specialty pharmacy's comprehensive service with the retail pharmacy's patient contact, giving patients options for medication delivery to home, pharmacy, or doctor's office. OBJECTIVE: Evaluate the impact of the new service model on medication adherence. DESIGN: Retrospective cohort study SETTINGS: One hundred fifteen CVS retail stores in Philadelphia participated in a pilot from May 2012 to October 2013, and 115 matched CVS retail stores from around the nation served as controls. PATIENTS: All eligible patients from the intervention and control stores received specialty medications through CVS retail pharmacies prior to implementation of the new service model. INTERVENTION: The intervention patients were transitioned from retail pharmacy service to the specialty pharmacy with delivery options. The control patients received standard retail pharmacy services. MAIN OUTCOME MEASURES: Proportion of days covered and first fill persistence were tracked for 12 months before and after program implementation. RESULTS: Under the new service model, 228 patients new to therapy in the post period had a 17.5% increase in the rate of obtaining a second fill as compared to matched controls. Patients on therapy in both the pre- and the post-periods had a pre-post increase of 6.6% in average adherence rates and a pre-post increase of 10.8% in optimal adherence rates as compared to 326 matched controls. CONCLUSION: The study demonstrated significant improvement in both adherence to therapy and first-fill persistence among patients in the new service model integrating specialty pharmacy's comprehensive services with the retail pharmacy's patient contact and medication delivery choices.

The Affordable Care Act's pre-existing condition insurance plan: enrollment, costs, and lessons for reform.

The Pre-Existing Condition Insurance Plan (PCIP) is the temporary, federal high-risk pool created under the Affordable Care Act to provide coverage to uninsured individuals with preexisting conditions until 2014, when exchange coverage becomes avail­able to them. Nearly 78,000 people have enrolled since the program was implemented two years ago. This issue brief compares the PCIP with state-based high-risk pools that existed prior to the Affordable Care Act and considers programmatic differences that may have resulted in lower-than-anticipated enrollment and higher-than-anticipated costs for the PCIP. PCIP coverage, like state high-risk pool coverage, likely remains unaffordable to most lower-income individuals with preexisting conditions, but provides much needed access to care for those able to afford it. Operational costs of these programs are also quite high, making them less than optimal as a means of broader coverage expansion.

Health care behaviors and decision-making processes among enrollees in a state high-risk insurance pool: focus group findings.

PURPOSE: To better understand the relationship between health insurance coverage and health care behaviors of persons with potentially disabling conditions enrolled in a state high-risk insurance pool. DESIGN: Six focus groups with risk pool enrollees at two sites. SETTING: Suburban areas in the state of Kansas. PARTICIPANTS: Forty-two individuals 29 to 62 years, all with potentially disabling physical or mental health conditions. METHOD: Qualitative analysis of focus group transcripts using pile sorting and theme identification. RESULTS: High premiums and deductibles limit participants' ability to afford basic health services and access to prescription medications despite their middle-class socioeconomic status. Participants report delaying or forgoing needed medical care because of lack of coverage and/or out-of-pocket costs. They employ numerous and potentially dangerous strategies to minimize costs, especially for prescription medications. Some report "saving up" needed procedures until their total costs will exceed that year's deductible. CONCLUSION: Individuals in the risk pool were making medical decisions on the basis of cost rather than need. Many shared stories of medical complications as a result of delayed care, and most expressed stress related to the difficulty of making decisions about their care and use of prescribed medications. The individual, nongroup insurance market, with its higher out-of-pocket costs, may not meet the needs of people with chronic health conditions.

Does high-risk pool coverage meet the needs of people at risk for disability?

State high-risk insurance pools serve people denied coverage because of pre-existing conditions. With benefit plans modeled on the individual market, these pools generally require higher out-of-pocket expenditures and provide fewer benefits than employer-sponsored plans, while their beneficiaries have very intensive needs. We profile 416 working adults enrolled in a state high-risk pool and document their health conditions and health care utilization. High-risk pool and federal employee benefits are compared to assess insurance structure and implications for health and disability outcomes.

Medicaid's expenditures for newer pharmacotherapies for adults with disabilities.

Medicaid's drug expenditures have grown at double-digit inflation rates since 2000. These prescription drug costs are important contributors to increasing health care costs for disabled persons. In spite of this knowledge, little has been reported about specific patterns of medication use among disabled enrollees. We analyzed Kansas Medicaid data to describe trends in medication use patterns across 3 years among disabled beneficiaries. The marked shifts toward newer medications and disproportionate contributions of newer, more expensive medications to overall prescription costs for antipsychotics, antidepressants, anticonvulsants, antiulcer medications, anti-inflammatory agents, and opioids have implications for both policy and practice.

An Insurer's Care Transition Program Emphasizes Medication Reconciliation, Reduces Readmissions And Costs.

Adverse drug events and the challenges of clarifying and adhering to complex medication regimens are central drivers of hospital readmissions. Medication reconciliation programs can reduce the incidence of adverse drug events after discharge, but evidence regarding the impact of medication reconciliation on readmission rates and health care costs is less clear. We studied an insurer-initiated care transition program based on medication reconciliation delivered by pharmacists via home visits and telephone and explored its effects on high-risk patients. We examined whether voluntary program participation was associated with improved medication use, reduced readmissions, and savings net of program costs. Program participants had a 50 percent reduced relative risk of readmission within thirty days of discharge and an absolute risk reduction of 11.1 percent. The program saved $2 for every $1 spent. These results represent real-world evidence that insurer-initiated, pharmacist-led care transition programs, focused on but not limited to medication reconciliation, have the potential to both improve clinical outcomes and reduce total costs of care.

Testing videotape education for heart failure.

This pilot study tested a videotape intervention designed to improve patient self-management of heart failure (HF). Content of the video series (produced professionally under a federal grant) is based on national, scientifically validated guidelines for HF home management. Outcomes tested were HF knowledge, symptom reporting, and functional status. Participants were 10 newly diagnosed HF patients (mean age 67). After viewing the tapes, data indicated participants had a clinically relevant improvement in HF knowledge, and improved or maintained HF health status. None were rehospitalized during the 60-day follow-up period. One patient contacted his/her physician to report weight gain, as prompted by the videotapes. The cost data indicated that patients paid $177 out of pocket monthly for medications and all were low income. These results indicate the need for further testing of the videotape as a potentially cost-effective method of teaching about HF self-management and daily home self-monitoring.

Impact of a patient-centered pharmacy program and intervention in a high-risk group.

BACKGROUND: The medication therapy management (MTM) program identified high-risk members in a large employer group and invited them to participate in an MTM program. The intervention consisted of at least 3 consultations with a clinical pharmacist to review and discuss drug therapy. The goal was to improve drug therapy adherence and clinical outcomes. OBJECTIVE: To assess the impact of MTM on plan-paid health care costs, utilization of medical services, overall days supply of targeted medications, and medication possession ratios (MPRs). METHODS: The MTM and control group comprised eligible members of a large employer prescription benefit plan who were identified between October 1, 2007, and November 12, 2008, and invited to participate. Control group members were selected from targeted members who declined. After propensity score matching to ensure similarity of groups at baseline, each group had 2,250 members. Baseline comparisons and post-period impact analyses between groups were conducted using bivariate analysis. Post-period analyses used tests for paired comparisons. The MTM and control group members were studied for the year before and after their individual program invitations. We measured pre-post differences between the MTM members and controls in total heath care costs, inpatient visits, emergency room (ER) visits, total days supply, and MPRs for 5 conditions: diabetes, hypertension, dyslipidemia, depression, and asthma. RESULTS: MTM members significantly reduced their plan-paid health care costs by 10.3% or $977, compared with an increase of 0.7% or $62 in the control group (P = 0.048). Inpatient visits in the MTM group decreased by 18.6%, while the control group experienced an increase of 24.2% (P less than 0.001). While both groups had decreases in ER visits, the groups were not significantly different (P = 0.399). Average days supply for the MTM group increased by 72.7 days over baseline; for the control group, it decreased by 111.1 days (P less than 0.001). MTM members with hypertension and dyslipidemia had pre-post increases in MPR of 2.29% and 2.10%, respectively, while the control group had decreases of 2.31% and 2.61% (both P less than 0.001). The mean MPRs for members with diabetes, depression, and asthma did not change in either group. Program costs per patient in 2009 were estimated to be $478. The program had a return on investment (ROI) of 2.0 in 2009. CONCLUSIONS: This study found that the pharmacist-managed MTM program to reconcile the medication therapies of high-risk patients and improve adherence, as measured by MPR, was effective in reducing total health care costs. The results show that those patients in the intervention group with hypertension and dyslipidemia had significant improvements in medication adherence, as compared with the control group. In fact, the intervention group used significantly more days of therapy in the intervention period, and the control group used significantly fewer days than either group used during the baseline period. MTM interventions were associated with a significant decrease in the MTM members' overall plan-paid health care costs, driven largely by decreases in inpatient utilization and mediated by increases in average days supply and in MPR increases for hypertension and dyslipidemia. Overall, the MTM program was cost-effective. The ROI estimated for this program of 2.0 is only slightly lower than the average disease management ROIs reported in the literature.

The validity of claims-based risk estimation in underinsured populations.

OBJECTIVES: To demonstrate a threat to validity in using claims-based risk tools with chronically ill, underinsured populations. STUDY DESIGN: We tracked disease burden of high-risk pool beneficiaries with potentially disabling health conditions receiving enhanced health insurance benefits through a federally funded research demonstration. At baseline, beneficiaries paid high premiums and cost sharing for risk pool coverage, and most met common criteria for underinsurance. Study benefits provided intervention group members premium and cost-sharing subsidies and additional coverage; control group members paid usual premiums and coinsurance and received usual benefits. We hypothesized that enhanced benefits for the intervention group would increase or stabilize health status measures and decrease case-mix weights, reflecting stabilized or reduced disease burden. METHODS: The SF-12v2 health survey was used to measure health status and the Johns Hopkins Adjusted Clinical Groups (ACGs), Version 8.2 with DX-PM model and prior cost for a non-elderly population, was used to measure disease burden. FINDINGS: Over a 3-year period, SF-12v2 scores showed stable health status for the intervention group and significant decline for the control group, while ACG case-mix weights, major illnesses, and chronic condition counts rose significantly for the intervention group but remained stable for the control group. Increased resource utilization for the intervention group appears to have driven increases in ACG measures. CONCLUSIONS: When high cost-sharing constrains access to care, risk tools that rely on medical claims may not provide an accurate measure of disease burden.

Transition to Medicare Part D: an early snapshot of barriers experienced by younger dual eligibles with disabilities.

OBJECTIVE: This study assessed the impact of transition from Medicaid drug coverage to Medicare Part D on a sample of dually eligible adults younger than age 65 years with disabilities. STUDY DESIGN: Telephone survey of employed adults participating in the Kansas Medicaid Buy-In program, Working Healthy, about their experiences in accessing medications after their transition to Part D. METHODS: A total of 328 (55%) individuals from a random sample of 600 agreed to participate in a survey administered by a university-based research unit during February and March 2006, which included 18 questions with yes/no, multiple choice, and open-ended responses. Participants resembled other Kansas dual eligibles demographically and medically, other than having slightly higher rates of mental illness and lower rates of mental retardation and some physical conditions. Participants' 2004 Medicare and Medicaid claims data were analyzed to obtain an overview of their comorbidities and previous prescription use. RESULTS: Twenty percent of participants reported difficulty obtaining medications, including drugs in Part D-protected classes; 13% were required to switch medications; and 8% stopped taking at least 1 medication. More than half did not know they could change plans monthly, potentially improving their access to medications. CONCLUSION: The high incidence of access problems despite Centers for Medicare & Medicaid Services (CMS) safeguards points to the need for ongoing monitoring of Part D. If the problems persist, CMS must be willing to modify the program and/or better enforce the rules already in place to avoid adverse outcomes for beneficiaries with disabilities.

A model for evaluating systemic change: measuring outcomes of hospital discharge education redesign.

Hospitals have restructured job duties and responsibilities in response to market pressures and in an effort to improve quality. This study presents a model for evaluating patient satisfaction outcomes following a work redesign that included the realignment of responsibility for discharge education from clinical nurse specialists to cross-trained, multidisciplinary workers. The outcomes data cannot be generalized, as they relate to a particular redesign and one institution. However, this analysis provides a framework for a systematic, multidisciplinary approach to evaluating organizational change.