While letters to patients and physicians were once the main mode of addressing medication nonadherence, PBMs and insurers are turning to predictive modeling in an effort to provide disease-specific, customized interventions to members at the highest risk for nonadherence and subsequent medical complications.

In its 2011 Drug Trend Report, Express Scripts Holding Co. estimates that the U.S. health care system spent $317 billion on treating medical complications that could have been avoided if patients had taken their medications.While letters to patients and physicians were once the main mode of addressing medication nonadherence, PBMs and insurers are turning to predictive modeling in an effort to provide disease-specific, customized interventions to members at the highest risk for nonadherence and subsequent medical complications.

In its 2011 Drug Trend Report, Express Scripts Holding Co. estimates that the U.S. health care system spent $317 billion on treating medical complications that could have been avoided if patients had taken their medications. As a result, the PBM is launching ScreenRx, a predictive modeling-based program that it’s been perfecting for years and contends is up to 98% accurate in identifying a member’s future risk for nonadherence.

Meanwhile, Prime Therapeutics LLC, a Minnesota-based PBM owned by 13 Blue Cross and Blue Shield plans, is about to expand its medication therapy management (MTM) program for Medicare Part D, incorporating predictive modeling and making it available to commercial members.

“We know with nonadherence that there is no one-size-fits-all solution,” declares Sharon Frazee, Ph.D., vice president of research and analysis at Express Scripts. “A letter to a physician or a phone call or a text [message] to a patient is not going to work for everybody.”

“In an effort to try to do something in a scalable, sustainable fashion [to manage nonadherence], predictive modeling becomes very important,” observes Peter Mikhail, Pharm.D., director of pharmacy services at Geisinger Health Plan. As part of a major overhaul of its medication adherence program (see story, p. 4), Mikhail says the health plan — which acts as its own PBM — is looking to purchase a software package that will do some of that modeling.

Frazee says her company constructed ScreenRx around two simple tenets: Detect early, and provide a tailored intervention that works for those populations. The predictive model considers more than 400 known factors about the patient, the physician, the disease and the prescribed therapy to identify who is most likely to stop taking their medication.

“Instead of looking back and saying, ‘Hey, you were late, you didn’t take your medication last year,’ which doesn’t help the patient very much, we’ll look for who’s likely to need a little extra help in the coming year, and then reach out to them to figure out what the barrier is for that particular patient,” explains Frazee. “Using that information, we can then have an intervention that’s targeted at their likely problem.”

The PBM has been testing its predictive models since 2010 with a 600-member pilot population (DBN 10/29/10, p. 1), but declined to share outcomes, saying not enough time had elapsed to have fully accurate results. “It’s looking promising enough that we’ve continued to invest in this for over a year,” teases Frazee, who expects to have outcomes in a few months.

The product will be available to clients later this summer for the categories of high blood pressure, high cholesterol, asthma, diabetes and osteoporosis. While the pricing model for ScreenRx has yet to be finalized, it will likely feature a separate per-member-per-year fee “that will be attached to a strong return on investment,” adds Frazee.

Cost Isn’t the Only Barrier

Through numerous patient surveys, Express Scripts has found there are multiple reasons why patients aren’t taking their medications as prescribed. Frazee breaks the causes into three groups and explains how the PBM can use each reason to customize outreach:

• 69% of nonadherence stems from behavior, such as forgetting to take medication (39%), delaying a refill (10%) and renewing late (20%). For those people who simply forget to take their medications, Express Scripts will mail them an audible timer device that’s affixed to the bottle with sticky tape and beeps when it’s time to take the pill. “It’s relatively inexpensive, and it’s just that little nudge that they need,” asserts Frazee.

• 16% of nonadherence is related to cost. For these patients, Express Scripts will move them to home delivery if there is a financial benefit or direct them to available patient assistance programs. “For those who simply can’t afford the medication, it would be inappropriate and ineffective for us to send them a little beeper that goes on the top of their pill bottle,” she adds.

• 15% of nonadherence is related to a clinical issue, such as patients worrying about being “medicalized” (i.e., “They don’t want to be the kind of person who takes medicine,” explains Frazee). Alternatively, patients may have questions about their medication or have concerns about side effects. Express Scripts refers this group to clinical pharmacists who can provide one-on-one consultations to allay their concerns and help them get a better understanding of their prescribed therapy. “If our pharmacist consultations identify the presence of a side effect that may be avoided through the use of a different prescription, we will provide that information to the patient and recommend that she contact her prescriber to discuss further.”

“Using that targeted and tailored approach, we’re able to figure out who needs help so that we’re not hitting everybody,” adds Frazee. “A lot of programs out there just reach out to every patient, for instance, taking diabetes medication, and not everybody needs help. Instead, we can use higher-touch resources for those who really need it.”

Prime Therapeutics, meanwhile, is in the process of launching GuidedHealth, an MTM product for its commercial business that will include adherence improvement through proprietary predictive modeling logic.

The new program will also feature disease-specific interventions for highest-risk patients. The PBM will review pharmacy and medical claims for its 8 million commercially insured lives and use proportion of days covered in a year — the adherence metric preferred by CMS — to identify people with a “qualified diagnosis.”

“In other words, we’re going to find the people who are at the highest risk for bad things to happen and who most need the drugs,” Pat Gleason, Pharm.D., director of clinical outcomes assessment, tells DBN. Less than 5% of all people in the Prime Therapeutics population qualify as highest risk, he adds.

The PBM will then reach out to patients and providers through a variety of methods. “To the provider, we could say, ‘We see that you made this diagnosis on this medical claim to our Blue Cross and Blue Shield plan that the patient had a heart attack, but we are not seeing a cholesterol-lowering drug — atorvastatin or any of the statins — in our pharmacy claims,’” explains Gleason. “And we can tell the provider, ‘We see that you’re prescribing other drugs to this patient, so we know that you’re taking care of them.’ We have logic to assign providers to individuals, too, and say, ‘We think it would be important if you initiate that statin therapy.’”

Gleason says providers have responded positively to this type of outreach, as the PBM has provided this service on a smaller level for its Blues plans and is now packaging it into the MTM product. GuidedHealth will provide tailored interventions in the classes of diabetes, high cholesterol, depression, respiratory and seizure drugs.

CVS Caremark Program Touts Big Savings

CVS Caremark Corp. also offers disease-specific interventions through its flagship Pharmacy Advisor program, which it launched for diabetes in January 2011 and recently extended to patients managing chronic cardiovascular illnesses (DBN 12/16/11, p. 1). Those programs saved clients an estimated $2.4 billion in 2011 through an increase in optimal adherence rates, according to the company’s most recent annual Insights Report, which also says nonadherence cost the U.S. $290 billion last year.

Through Pharmacy Advisor, CVS Caremark reaches out to members at risk of falling off their drug regimen via strategically timed face-to-face and phone interventions, depending on how the member typically obtains his or her prescription (i.e., via a retail store or mail-order facility). While there is a call center, retail pharmacists may also make outreach calls if a patient is late in obtaining a refill or picking up a new prescription and offer condition-specific counseling and educational brochures.

The company plans to broaden that program to include more chronic conditions and deepen interventions for patients with the most complex conditions such as offering in-home pharmacist visits to members recently discharged from the hospital to prevent readmissions. CVS Caremark says three in four readmissions are related to nonadherence.

While Pharmacy Advisor does not have a predictive modeling component, company spokesperson Christine Cramer tells DBN, “We are looking at predictive modeling right now from a research standpoint to be able to collect the evidence necessary to show it works. It is something we continue to look at.”

Letters Still Can Get Members’ Attention

While predictive modeling remains largely untested, some insurers are sticking to their letter-writing campaigns but changing their approach.

“Letters, unfortunately, don’t get a high return,” sighs James Hopsicker, vice president of pharmacy programs at MVP Health Care, which serves more than 750,000 members in New Hampshire, New York and Vermont. “You have to keep sending letters, so we’re trying to find more effective ways to reinforce or use other technologies, but we’re not there yet. We’d like to be able to have every member’s email address, but we don’t have that at this point.”

In the meantime, for those patients who are shying away from filling prescriptions due to financial concerns, the not-for-profit insurer has found that showing annualized savings by switching to the generic is a more effective message. “When you say, ‘You can save $240 a year per prescription rather than $10 or $20 a month,’ it tends to get people’s attention,” asserts Hopsicker.

BlueCross BlueShield of Tennessee, meanwhile, reaches out to patients if they have a first prescription fill in certain high-risk disease states such as osteoporosis and asthma or if they fall off after that first fill. “We’re working very hard to make sure that patients understand the importance of taking their medications as prescribed. Of course, there’s always room for improvement,” adds Beverly Franklin-Thompson, director of regional pharmacists.

© 2012 by Atlantic Information Services, Inc. All Rights Reserved.

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