# Presentation: 700733

## Models for Effective Medication Use in Health Care Systems

- Susan J. Curry, Ph.D.
- University of Illinois at Chicago

## Models for effective medication use in health care systems for treatment of tobacco use and dependence should be consistent with models for treatment of other chronic conditions  

## Chronic Care Model

## Medication can be used effectively if it is:
Available
Affordable
Appealing
Appropriately used

- Available
- Affordable
- Appealing
- Appropriately used

## Making Medications Available:  Formulary Decisions  

- Prescription drug costs up 19% in 2000
- 36% of increase due to new, >$ drugs
- higher drug costs not offset by lower medical costs
- Insurers & MCOs control costs and outcomes by making evidence-based decisions on whether to place new drugs on formulary

## Formulary decisions

- Focus on clinical outcomes as well as economics
- Made by committee
- Use standardized guidelines

## Regence BlueShield Formulary Guidelines

- Regence clinical pharmacists complete detailed review of each drug based on clinical literature.
- Medical literature on efficacy, effectiveness and relative safety is foundation for formulary review
- FDA “AB” rated generics will generally be preferred

- Mather et al, A J Man Care, 1999;5(3):277-285

## Regence BlueShield Formulary Guidelines

- Brand names only included when offer value (e.g., significantly more clinically effective than generics or other brands in the same therapeutic class)
- When clinical studies show that several drugs are clinically equivalent, only the products with the lowest net cost will be included in the formulary

- Mather et al, A J Man Care, 1999;5(3):277-285

## Regence BlueShield Formulary Guidelines

- Improved dosage forms only considered when their cost effectiveness can be documented
- For each drug, manufacturers are required to submit dossiers that include detailed clinical and economic information, including data from published and unpublished studies, and outcomes modeling

- Mather et al, A J Man Care, 1999;5(3):277-285

## Regence BlueShield Formulary Guidelines

- Economic modeling will be used to evaluate the impact of each drug on patients’ clinical outcomes, medical claims, and costs of care.

- Mather et al, A J Man Care, 1999;5(3):277-285

## Formulary decisions bottom line

- ‘Burden of proof’ is on the medication (and, by extension the manufacturer)
- As number and types of pharmacotherapies for tobacco use cessation increases there will be increasing demand from health systems for data on their relative clinical and cost effectiveness

## Making medications affordable:  Insurance coverage

- Use goes up with full coverage
- 25% vs. 14% used NRT over 12 months  (Schauffler et al, Tob Cont, 2001)
- But not always...
- 19% vs. 24% used Zyban
- 28% vs. 26% used NRT over 12 months  (Boyle et al, Health Affairs, 2002)

## Making medications affordable:  Insurance coverage

- The more it costs, the less it’s used
- 50% co-payment on NRT associated with 31% drop in use (Curry et al, NEJM, 1998)
- Many with coverage don’t know they have it
- 30% in Boyle study knew of coverage
- Use of medications higher if aware of coverage (42% Zyban; 31% NRT)

## Making medications affordable:  Insurance coverage

- How benefit is structured can impact availability and use of new medications
- Bundled with behavioral program
- Coverage for specific medications or all FDA-approved
- Amount dispensed per prescription

## Making pharmacotherapy appealing

- Does prior failure with pharmacotherapy reduce demand for new treatment?
- National data not available, but RTC data suggest not
- Over 60% of volunteers for Zyban effectiveness trial had prior use of NRT
- Pharmacotherapy may have inherent appeal to smokers looking for the ‘magic bullet’

## Making pharmacotherapy appealing

- Pharmaceuticals’ investments
- Direct-to-consumer marketing
- Academic detailing for clinicians
- Health care system investments
- vital sign stamps, chart stickers for easy identification of smokers
- medical record prompts for advice, assistance
- clinical information systems and registries for follow-up

## Facilitating appropriate use

- Medication approval in efficacy trials
- face-to-face prescribing
- regular monitoring & behavioral support
- Medication use in effectiveness conditions
- over-the-phone prescriptions
- under-dosing (amount &/or duration)
- concurrent smoking
- no behavioral support

## Facilitating appropriate use:  Behavioral support 

- Bundled coverage ensures behavioral support
- Seamless protocols for obtaining pharmacotherapy as part of behavioral program ensures medication use

## Facilitating appropriate use:  Behavioral support

- Integrated Model*
- Telephone-based enrollment & screening for medication eligibility
- case review for questionable, ineligible by program physicians
- notification of potential medication use to patient’s primary care provider
- Medications and written behavioral program materials sent by mail

- *From Swan, McAfee, Curry et al, Arch Int Med (in press)

## Facilitating appropriate use:  Behavioral support

- Integrated model, cont’d
- Patient enrolled in state of the art telephone counseling program(4 outreach calls over 6 months; access to toll-free quitline for 1 year)
- Treatment progress reports sent to primary care physicians

## Facilitating appropriate use:  Behavioral support

**Dose OR       = 1.05 [0.94,1.17]**
**Program OR = 1.21 [1.08,1.35]**

## Moderate intensity behavioral programs do improve long-term outcomes
Can be provided ‘in-house’ or through linkages with community-based programs (e.g., state quit-lines)

- Can be provided ‘in-house’ or through linkages with community-based programs (e.g., state quit-lines)

## Re-cap

- Medications must be available
- May be a higher bar for new medications
- Affordability is important
- Particularly for lower income smokers where prevalence is increasingly concentrated
- Chronic disease care models in health care systems are appropriate
- Behavioral (self-management) support is a key component