By Martin Burruano, R.Ph. – Vice President, Pharmacy Services

In the U.S., prescription drug spending totaled $500 billion in 2021, an increase of 7.3% from 2019, according to a March 2022 report by the Drug Channels Institute.

Addressing the complex drivers of health care costs takes collaborative approaches with providers. As Western New York’s only locally based health plan, Independent Health works in partnership with physicians and providers to implement solutions to deliver quality and value in pharmacy benefits. Our long-standing relationships with providers enable us to work closely with them to help influence change.

To do this, our pharmacy engagement team shares reporting with practices on quality and prescribing patterns compared to their peers. This interaction not only assures the providers have access to the prescriptions they need to treat their patients, but that they also have access to data to help them deliver quality, cost-effective drug management.

Our clinical pharmacists use detailed analysis from national sources and our own expert analysts to monitor trends that enable us to proactively be in front of the changing environment and enact solutions which involves: 

  • Collaborative initiatives with providers to improve medication adherence, reduce waste and improve quality.
  • The use of a clinically-driven, value-based drug formulary built on clinical effectiveness, safety, need and value, with input from Western New York providers.
  • Evidence-based protocols to ensure clinical appropriateness and outcomes.
  • Provider engagement activities encouraging clinical quality and cost-effectiveness.

Here are some initiatives that exemplify the work underway at Independent Health. 

$36 million savings through better specialty drug management

Specialty medications represent less than 1.5% of pharmacy utilization, but their cost is approaching 50% of all drug expenditures. While specialty medications are necessary to address serious medical conditions, variation in care and inconsistent use of medications are part of the rising costs.

Independent Health partners with an industry-leading company to deliver evidence-based criteria in management of specialty medications, primarily in the areas of oncology, immunotherapy and rare diseases.

This review process enables peer-to-peer conversations to ensure clinical appropriateness, optimal use of medications to reduce waste, and ensures Independent Health is effectively managing premium dollars.  In addition, Independent Health anticipated this trend several years ago, and established its own specialty pharmacy division, RelianceRx, in 2010. 

Results of our efforts*:

  • In 2021, this process saved $5.6 million by promoting an evidence-based approach to appropriate drug management, with a total savings of $36 million since 2016 on the commercial line of business alone.
  • Through the work of RelianceRx, which conducts patient counseling and education, helped Independent Health save $7 million in 2021 as well in eliminating unnecessary costs through inappropriate use.

Provider engagement improves diabetes drug management

Diabetes medications account for the highest drug spend category for Independent Health, at 10% of drug costs.

Brand-name medications, a large contributing factor, can be costly treatments that don’t add value, compared to equally effective and more cost-efficient generic drugs that have a proven track record of helping patients achieve lower blood glucose levels. For example, the average cost of a brand name diabetes medication after the rebate is more than $500, while the average cost of the generic is $20.

Through a provider engagement initiative to increase the use of a proven agent (metformin) as a first-line medication and reduce the use of low-value, high-cost drugs, we have seen significant decrease on overall blood glucose levels among our members. 

Results of our efforts*:

  • More than 72% of our members are prescribed metformin, a 10% increase over 2020.
  • Only 6.1% of members are now prescribed high-cost, low value brand diabetes medications – which is a 35% decrease in utilization from 2019, and a $500,000 savings, while still maintaining diabetes clinical control as we have seen a significant decrease in A1C levels.

Use of Biosimilars to achieve value

Biologics are types of medications or mixtures made from living organisms and used in the prevention, diagnosis, or treatment of cancer and other diseases. They include gene therapies, monoclonal antibodies and vaccines. Biosimilar products are FDA-approved medications that are extremely similar to their reference biologics. Because the cost of biologics is significantly expensive, Independent Health has required the use of biosimilars when available (for example, oncology drugs Avastin, Rituxin and Herceptin. 

Results of our efforts*:

  • Independent Health has contracted with a single biosimilar manufacturer which enables us to achieve greater savings.
  • The use of biosimilars has achieved $300,000 savings in 2021. 

Awareness and Education improves appropriate opioid usage

Independent Health shares the community’s concern over the extent of substance use disorder and death related to opioid usage. Recognizing that opioids still have a place in pain management, Independent Health’s opioid management program ensures safe and effective use among our members who need these medications. As part of the program, we instituted a 7-day supply quantity limit for first-time opioid prescriptions to help physicians assess the medical need for a refill, and conduct peer reporting to prescribers so they are aware of their prescription volume. 

The pharmacy team is closely integrated with our care management teams to determine quantity limits, and identify duplicate prescriptions and early refill requests. In addition, we remind prescribers about safety and ways to mitigate adverse outcomes, and we inform members receiving their first prescription of an opioid about the risk and addictive potential of opioids.  Ongoing safety monitoring is also part of this process.

Results of our efforts*:

  • The collaborative effort has reduced opioid drug use while maintaining members’ access to the important medications by 24% since 2018.
  • Independent Health provides reporting and education on the usage and risks of combining opioids with benzodiazepines, which can lead to accidental overdose.  Our interventions, which include provider detailing and member education strategies, have resulted in a 32% decrease in combination prescriptions and a 55% decrease in member use.

As new medications are introduced to the market, Independent Health continues to monitor their efficacy, value and cost against existing and proven therapeutics. Our tactics to address these challenges may change but our strategy to involve providers and deliver better value is always at the forefront of our approach.

*Results apply to commercial line of business only.

Photo by Roberto Sorin on Unsplash