Ann L. Woloson,

Executive Director

Jennifer Reck,

Policy Analyst

Prescription Policy Choices

Show Me the Evidence Ensuring Access to Safe, Effective and

Affordable Prescription Drugs

2011 International Symposium on Safe Medicine

October 4, Portland, Maine (image from http://www.deskpicture.com/DPs/Nature/Autumn/FallScene_1.html)

Prescription Policy Choices (PPC)

Nonprofit, nonpartisan 501(c ) (3) educational & public policy organization providing objective research, information and expertise on prescription drug policy to ensure access to safe, effective and affordable prescription drugs in Maine and the US

Foundation & Consumer Advocacy Group Funding: Nathan Cummings Foundation, Endowment for Health, Maine Health Access Foundation, Bingham Program, Consumers Union, Community Catalyst-Pew Prescription Project, Sadie and Harry Davis Foundation, Maine Community Foundations

Evidence-based prescribing: Most effective, safe and cost-effective drugs

Uses unbiased, objective information (the science) about the relative effectiveness, safety and cost-effectiveness of Rx drugs

Improves health care quality Helps maintain access to health care services by investing

resources wisely Reduces prescription drug (and health care) costs “Preferred” does not always mean “evidenced-based” or best

value

Rising Expenditures for Rx Drugs

2008 US spending for Rx drugs was nearly 6 times that spent in 1990 ($234.1 billion in 2008, $40.3 billion in 1990)

One of the fastest growing health care cost components, until early 2000s, growing at double-digit rates

Rx drugs contributed 13% of the total growth in national health expenditures from 1990 to 2008.

$58 billion estimated by the New England Healthcare Institute to be wasted on misuse, overuse & underuse of prescription drugs in 2008

Government share of prescription drug spending increasing (Kaiser: Rx Drug Trends, 5/10)

PPACA and Medicare affecting Rx coverage/spending

ACA: – Medicaid expansion for uninsured adults– Rx drugs are “essential health benefits” (included in the

exchanges and “benchmark-equivalent” for new eligibles under Medicaid)

– Changes in rebates (Feds to retain increases in rebates to certain amount)

Medicare: – 50% discount for brand name drugs for beneficiaries in the

doughnut hole/gap starting in 2011– 7% discount for generics annual phase in – Coinsurance phase-in over time for both brand and

generics

Pharmaceutical Industry Marketing

Industry marketing in 2009– $10.9 billion

$6.6 billion direct to physicians; $4.3 billion direct to consumers

(Kaiser Family Foundation)

In Maine:– $68 million in 2007– $90.6 million in 2008

Evidenced-based Drugs: Three Points for Impact

1. Prescribers – Academic detailing/prescriber education (counters drug reps

in prescriber’s offices)

2. Consumers– Consumer Reports Health Best Buy Drugs™ / Consumer

component to academic detailing (counters direct-to- consumer advertising)

3. Payers– Drug Effectiveness Review Project (DERP), AHRQ Effective

Healthcare, Consumer Reports Health Best Buy Drugs™

Providers/Prescribers: Maine Independent Clinical Information Service (MICIS)

Maine’s academic detailing (prescriber education) program

– Educational outreach to prescribers at practice site– Balanced data about medications based on evidenced-

based, independent, non-commercial sources – Current clinical modules: Adult Type 2 Diabetes, Antiplatelet

Therapy, Hypertension, Atrial Fibrillation, Chronic Pain Management

– Upcoming: Anti-psychotics– Administered by the Maine Medical Association

www.mainemed.com

Maine Independent Clinical Information Service (MICIS)

Newest module:

Helping the hurt without hurting the patient: outpatient management of chronic pain

Covers pharmacology of pain management:Acetaminophen,   NSAIDS,  opiates  and  opiate- like  agents, anticonvulsants   and  antidepressants  Comparative safety, efficacy and costs of pain medicationsAttenuating  the  risks  of  adverse  events  from  pain  medications  Guidelines  for  reducing  the  risk  of  opiate  addiction  and  misuse

To request an educational session on this module or others,

contact the Maine Medical Association:

207.622.3374 or academicdetailing@mainemed.com

Maine Independent Clinical Information Service (MICIS)

Impact:– Over 1300 modules detailed to more than 750

unique prescribers in Maine– 76% reported that they plan to change their

prescribing habits based on information from a MICIS educational module

Consumer engagement

80 drug ads every hour, every day on TV (Nielsen Co.)

30% of people have spoken to their doctors about a drug ad; 44% got the prescription they asked about (Kaiser Family Foundation)

PPC is working with Consumer Reports Health Best Buy Drugs™ to promote evidence-based drugs

Vision: independent scientific evidence (what works best, is safest, and most often, more affordable - not branding and marketing - should drive consumers

Consumer Reports Health Best Buy Drugs™

What works best, is safest and most cost-effective (tried and true)

www.CRBestBuyDrugs.orgReports

Drugs to treat high cholesterol: The Statins / Drugs to treat hepatitis CDrugs to treat rheumatoid arthritis/ Migraine Headache Drugs – the Triptans

Drugs to Treat Enlarged Prostate / Osteoarthritis, Pain – the NSAIDsDrugs to Treat Muscle Spasms and Spasticity: Muscle Relaxants

Drugs to Treat Nausea and Vomiting: The Oral 5-HT3 Antagonists Drugs for Heartburn, Acid Reflux Disease - the PPIs

Drugs to Treat Schizophrenia and Bipolar Disorder /Antidepressants Attention Deficit Hyperactivity Disorder Drugs

Angina, High Blood Pressure – Calcium Channel BlockersHigh Blood Pressure, Heart Failure – the ACE InhibitorsHeart Disease and High Blood Pressure – Beta-Blockers

Treating Type 2 Diabetes – the Oral Diabetes DrugsConstipation Drugs / Menopause – Hormones/ Sleeping Pills for Insomnia

Treating Chronic Pain – the OpioidsTreating Bipolar Disorder, Nerve Pain and Fibromalagia – the Anticonvulsants

Treating Heart Disease, Heart Attack, and Stroke – AntiplateletsOveractive Bladder / Asthma and Lung Disease – Inhaled SteroidsA l z h eim er ’s Disease Drugs/ Allergies, Hay Fever, and Hives – Antihistamines

Consumer Magazines

Best Buy Drugs offers a free, independent consumer magazine free of advertising

Request copies through PPC by contacting 512-2138 or jreck@policychoices.org

Compare to WebMD Magazine– includes many advertisements – sponsored sections are not reviewed by the WebMD

Editorial Department for accuracy, objectivity or balance

Payers: Lewin Group Study (12/2010)

Identified $30 billion in state savings over the next decade beyond rebates

– Savings associated with improved pharmacy benefit management from Medicaid managed care organizations

Generic utilization (68% in Medicaid FFS vs. 80% in Medicaid MCO) Dispensing fees & ingredient costs (higher for FFS than MCO) Drug Utilization (evidence-based)

Estimated 14.8% reduction → Lewin estimates these approaches could yield14.8% savings for pharmacy spending

($14 mil for ME)

Payers: Minnesota Study*

Increasing the utilization of evidenced-based recommended drugs can yield cost-savings of more than 50% (for drug categories studied)

Achieved through formulary/ PDL changes that incentivize value-based utilization of prescription drugs

*Kjos, AL, et al. A comparison of drug formularies and the potential for cost-savings. American Health & Drug Benefits, vol 3, No. 5 (September/October 2010): 321-330.

Payers: Avandia Example

ME: Avandia was listed as preferred in 2009 Avandia sales peaked at about $3 billion in 2006 - world’s best-

selling diabetes Type II med. Sales dropped sharply after a 2007 NE Journal of Medicine report linking it to increased heart attach and

cardiovascular death risks Metformin, a generic drug, is recommended drug

alternative (supported by DERP/CRHBBD™) Estimated potential savings for replacing Avandia with

metformin in 2009: $150,000 (does not include potential savings related to improved quality)

Evidence-based Resources for Medicaid

DERP

Collaboration of public entities (the Center for Evidence-based Policy and the Oregon Evidence-based Practice Center) that produces systematic, evidence-based reviews of the comparative effectiveness and safety of drugs in many widely used drug classes in order to inform public policy and related activities in local settings

Medicaid Evidenced-based Decisions Project

Provides participating states with high quality evidence and analysis to support benefit design and coverage decisions made by state programs (Alabama, Alaska, Arkansas, Minnesota, Missouri, New York, Oklahoma, Oregon, Washington Wisconsin, West Virginia)

Payers

Are States working to make sure public health programs are incentivizing the use of the best, most effective and safest drugs?

Are states using evidence-based information? How are States integrating evidenced-based

information into Rx drug coverage decision-making processes?

Payers

Generic medications will continue to offer

greater value than brand-name medications for most patients

Encouraging cost-effective medication use, regardless of levels of subsidies applied, will reduce … overall out-of-pocket costs as well as federal outlays for prescription medications, allowing health care resources to be used more efficiently.” (Shrank, W. & Choudhry, N. NEJM p 1011625, Jan. 19, 2011)

Resources

Consumer Reports Health Best Buy Drugs™ www.CRBestBuyDrugs.org

Drug Effectiveness Review Project (DERP)

http://www.ohsu.edu/xd/research/centers-institutes/evidence-based-policy-center/derp/index.cfm

AHRQ Effective Healthcare Program

http://www.effectivehealthcare.ahrq.gov/

For more information

Please visit www.policychoices.org

Contact information:

Ann Woloson

awoloson@policychoices.org

Jennifer Reck

jreck@policychoices.org

207-512-2138