MANAGED CARE July 2005. ©MediMedia USA
The plan du jour requires a different mindset and approach in order to succeed. Be sure to include incentives.
What's the difference between the pharmacy benefit in a consumer-directed health plan and a traditional health plan? Greater generic drug utilization is the overriding answer.
But that increase may be the only provable measure of change seen with CDHPs to date.
"Adopting a CDHP is a two-fold process," says Al Heaton, director of pharmacy at Blue Cross Blue Shield of Minnesota. "Very early on, within the first month of rolling out a CDHP, you don't see a lot of behavior change among members because not everyone gets a prescription filled or not everyone sees a physician. There is a catch-up phase.
"In our CDHP products, utilization is down about two prescriptions per member per year and the use of generics is way up. The prescriptions for nonsedating antihistamines, proton-pump inhibitors, NSAIDs — even before COX-2s were taken off the market — have dropped. But for our members with chronic conditions — heart disease, diabetes, depression — their utilization rates are stable."
Eric Estes, RPh, vice president for sales and product management for pharmacy at Aetna, says that the metrics Aetna follows to see the effect of these plans "start with the use of consumer tools. Members can use Aetna's secure Web site to identify the drug that they are about to take or are currently taking. The site shows members the price of the medication, and they see alternate medications that might be just as effective, but that cost less.
"So one of the metrics that we use is the number of members who are signing up for access to the Internet site," Estes continues. "We can also see the amount of traffic going to the site.
"We are also seeing an increase in mail order benefit in the CDHP population. Generally speaking, the mail order benefit becomes a cost-effective delivery system at a reduced price, in some cases when compared to the retail price."
How does a consumer-directed plan factor in the idea that sick members should pay less for drugs?
"There are some ways a CDHP responds to that way of thinking," says Estes. "Employers can determine funding amounts before the plan is implemented or employers can decide how to divide the benefit between the pharmacy and medical side. So for members who need chronic therapy, that may carry a lower copayment than an acute therapy. Generic drug versus branded drug comes into play here: Most of our chronic therapy has been available for so long that a generic version is available. And members who are very sick are protected by a cap on out-of-pocket costs."
Tim Kotas is vice president for product development at Lumenos, a consumer-directed health plan that has been acquired by WellPoint. "There are also ways to design incentives for the individuals with a chronic condition," says Kotas. "We've provided the consumer with health coaches and established graduation requirements. If a consumer in our plan calls to speak with a health coach about his condition, he's paid between $50 and $100. If the consumer participates in health coaching classes, learns about his condition, and achieves health goals, he receives between $100 and $200 for participating in and graduating from the program. That money goes into his funded account.
"It's thinking about the consumer as the payer," continues Kotas. "You need to trust that the consumer can be educated and competent in making health care decisions."
Kotas characterizes the level of involvement in a traditional health plan compared with the involvement in a consumer-directed health plan as equal, but different.
"The best-practices model design has to be retooled with the consumer in mind," he says. "For example, CDHPs need to give the consumer the questions to ask the physician. Providing the price of drugs is a start, but it's not enough. They should list alternate treatments, including generic and over-the-counter options. The ability to sort the drugs by price is useful to the consumer."
In Lumenos's version of CDHP, the consumer sees the discounted and nondiscounted cost of the drug, with the mail order or retail cost clearly designated. The pricing is set at the plan level.
While Kotas says there is a "different level of involvement" for the pharmacy benefit, Al Heaton of Blue Cross Blue Shield of Minnesota, says there is more involvement.
"Pharmacy is one of the most commonly used benefits," says Heaton. "Nationwide, people are averaging about one prescription a month. They're not averaging a laboratory test or an office visit every month.
"And in many respects, the pharmacy benefit is well-suited for consumer-directed health plans," continues Heaton, "because of the ability to see account balances, to see deductions, and to understand what these drugs really cost.
"That's why we see such a turnaround, in terms of costs and generic utilization, on the pharmacy side, because heretofore, the consumer only had a $10 or $15 copayment. The cost has been hidden. In these types of plans, the costs are visible, and the consumer sees the costs very quickly." Heaton says that BCBS Minnesota's CDHP offering has on average a 7-percent higher generic drug utilization rate than its conventional plans.
Estes says that helping consumers make good choices about drug therapy is more than helping the member have a good conversation with his physician.
"It's not just having the physician do the prescribing, but allowing the patient to participate in a discussion before the prescription is written," says Estes. "The discussion should include not just cost but also compliance and appropriate care, so that the patients understand the course of treatment they are about to undergo.
"Members going to the doctor might prepare by identifying the different types of medications used to treat their condition," continues Estes. "For example, after having a cholesterol test completed, the member may receive a call from the doctor's office requesting a visit to discuss treatment for elevated cholesterol. By going to the Web and printing a list of all of the drugs in the treatment category, he will be able to discuss the alternatives. This discussion should include effectiveness, generic availability, side effects, and claims costs and amount of copayment."
Barriers to success
Even after changing philosophy, companies offering CDHPs will run into barriers. Perhaps the greatest barrier is data integration — the ability for the claims data processing that is carried out at the pharmacy to be accurately reflected in the member's account online with noted deductions immediately, in real time.
Data integration can be a barrier, especially when the CDHP covers both the medical and pharmacy benefit through the same reimbursement account. The CDHP must be able to distinguish the medical from the pharmacy charges, and be able to quickly communicate updated information to members. These plans rely on giving members immediate access and information so they know how much they have spent and how much is left for pharmacy coverage. Heaton explains that when members get a prescription from a physician, often, that prescription is filled the same day.
"But physician offices may or may not have electronic billing," says Heaton. "They may be submitting paper claims, which may show up two months later. One of the areas that we've made great strides in is making sure we have electronic billing on the physician side to accommodate CDHPs. If you have old paper claims on the physician side, it's hard to keep up with the pharmacy side and often the billing cycles are different.
"In the real time point-of-service world, which the pharmacy operates in, we had to create an environment where members could go in, access their pharmacy benefit, and not interfere with the pharmacist's ability to adjudicate the claim," Heaton says of the BCBS Minnesota version of CDHP, which has about 90,000 members. "We wanted to create a system that wouldn't interfere with the pharmacy process."
The response from providers has been somewhat muted. "They don't typically practice this way," says Heaton. "Based on the limited feedback I've seen, most providers do not know what this benefit design is all about. Most comment that they're getting more questions from their patients: 'How much does this cost?' or 'Is there something available OTC now that will work, too?'
"Employer groups like this type of benefit design. They see changes in utilization [the number of prescriptions filled] and the cost per prescription. We had a couple of groups that were early adopters two years ago. They went from 38 percent use of generic drugs to 63 percent within a month of adopting a CDHP."
Estes, the Aetna official, says that another barrier may be the actual price of the drug as consumers recoil from sticker shock, "but we haven't seen that to be the case so far. Our studies are showing a significant increase in the use of generic drugs and a decrease in prescription utilization. On the other hand, we have not seen a decrease in compliance with chronic or maintenance drugs."
"Once the consumer gets used to seeing his account balances, he becomes a pretty savvy shopper," says Heaton. "Consumers ask if they really need the drug, or if a generic version is available."
But will consumers care about this ability?
They will care if they have a stake or an incentive says Kotas. An effective consumer-directed plan is going to include "price transparency, choice, and the ability for the consumer to save directly," says Kotas. He goes on, "our plans and tools are designed to allow consumers to prospectively compare prescribed drugs to all the alternatives, including other brands, generic versions, and over-the-counter options.
"But the challenge is that everyone has a different definition of what a consumer-directed health plan should entail. If you believe that CDHP is merely cost-shifting, but in a different form, then it will not work. What makes CDHP different from the traditional plan is that CDHP provides the consumer with incentives to make the right decisions.
"To be successful, two characteristics need to be designed into the plan: one, the ability to access information and act on that information must be convenient and straightforward for the consumer, and two, the incentives have to be properly aligned so that if there is any money to be made, it should go to the consumer."
The movement toward consumer-directed health plans is part of a bigger picture to push consumers to both understand the true costs of today's health care and to bear more responsibility for their overall financial and physical health. The pharmacy benefit is well-suited for this push, although it requires a shift in focus — making consumer adoption easy and convenient.
Sample of a CDHP account available online
Members can use the Lumenos Web site to see the price of the medication and they can review alternate medications that may be just as effective, but cost less.