# Presentation: 540477

## Stephen Soumerai, Sc.D.ProfessorDepartment of Ambulatory Care and PreventionHarvard Medical School and Harvard Pilgrim Health Care

**Designing Pharmacy Benefits to **
**Improve Quality and **
**Contain Costs**

**Notes:**
“soumerai intro slide”

## Evolution of Prescription Drug Benefits Designs	

- Non-selective “blunt” tools can have unintended consequences, reduce clinical effectiveness, and increase total costs
- Caps on number of prescriptions
- Non-selective cost sharing
- Triplicate prescriptions

**Notes:**
“evolution”

## Evolution of Prescription Drug Benefits Designs (cont’d)

- Initial studies suggest that selective “sharp” tools that recognize relative effectiveness of drugs within a class can reduce inappropriate use and promote least-costly alternatives
- Reference pricing
- Tiered copayments
- Evidence-based preferred drug lists and formularies

**Notes:**
“evolution-ctd”

## Unintended effects of non-selective cost-sharing policies 

- Reduces use of clinically important medicines (e.g., insulin, cardiac meds)
- Increases use of institutional services
- Nursing homes and hospitals (elderly)
- Day hospital and acute care (patients with schizophrenia.)
- May increase total health care costs
- Mental health cost offsets 17 x drug savings

**Notes:**
“unintended”

## Time Series of Constant-Size Rxs per Continuously Eligible Patient per Month among Multiple Drug Recipients (N=860) and Other Outpatients (N=8002)

- Source: Soumerai et al, N Engl J Med 1987; 317: 550-6

**Notes:**
“time-series”

## Cap-induced Changes in Essential Drugs: “Droppers” vs. “Maintainers”

**0**

**1**

**2**

**3**

**4**

**STANDARD DOSES PER ELIGIBLE PERSON**

**BASELINE**

**3 DRUG CAP**

**$1 COPAY**

**JUL ‘81**

**JUL ‘82**

**JUL ‘80**

- Source: Soumerai et al, N Engl J Med 1994; 331: 650-5

**Notes:**
“cap-induced”

## Effects of Prescription Cap on Nursing Home Admissions

**80%**

**85%**

**90%**

**95%**

**100%**

**Baseline**

**Cap**

**After Cap**

**% outside nursing home**

**New Jersey**

**New Hampshire**

- Source: Soumerai et al, N Engl J Med 1991; 325: 1072-7

**Notes:**
“effects”
Similarly, residents living in the cap state, New Hampshire, were 2 times as likely to go into nursing homes after the cap was implemented than those in New Jersey.  Also, this trend did not reverse itself, but merely leveled off, once the cap was repealed.  

## Effect of Cap on Emergency Mental Health Services

**Baseline**

**Cap**

**After Cap**

- Source: Soumerai et al, N Engl J Med 1994; 331: 650-5

**Notes:**
“emergency”

## Changes in Use of Essential Drugs With Change in Cost Sharing

- Source: Tamblyn R et al, JAMA 2001; 285: 421-429

**Notes:**
“essential”

## Effect of a $0.50 per Rx Copayment on Medication Use by Medicaid Recipients in South Carolina

- Source: Nelson, Reeder & Dickson. Med Care Aug. 1984 p. 724

**Notes:**
“copayment”

## Impact of Triplicate Prescription Program (TPP) on Benzodiazepine (BZ) Prescribing

**New Jersey**

**New York**
**(-54.8%)**

- Source: Ross-Degnan et al (submitted)

**Notes:**
“Triplicate”

## Impact of TPP on Use of BZ Indicated for Seizure and Panic Disorder

- Source: Ross-Degnan et al (submitted)

**Notes:**
“TPP”

## Reduction in BZ Use Among Patients with Seizure Disorder

**NY Study Cohort**

**NJ Control Cohort**

- Source: Simoni-Wastila et al (submitted)

**Notes:**
“BZ”