Martin Sipkoff
MANAGED CARE September 2008. ©MediMedia USA

A low return on investment and high implementation costs keep dose optimization from taking hold in some pharmacy benefit programs

With more than a dollar out of every $10 in health care costs spent on drugs, health plans and pharmacy benefit management companies search for as many ways to save money as they can. But sometimes an approach does not live up to expectations. Dose consolidation, sometimes called dose optimization, may be one such idea.

Sounds like a good idea

The basic idea behind dose consolidation is that if plans or PBMs encourage physicians to prescribe a once-daily tablet instead of two lower-strength tablets when per-tablet cost is identical, they can lower drug costs. On the surface it seems like a good idea, but in one study, Express Scripts found that once administrative costs are taken into account, it may cause more trouble than it is worth.

Dose consolidation works, “but the problem is that there is not much return,” says Thomas Delate, PhD, clinical pharmacy research scientist for Kaiser Permanente of Colorado.

“We found that it works, but the problem is that there is not much return,” says Thomas Delate, PhD, clinical pharmacy research scientist for Kaiser Permanente of Colorado and former outcomes research manager for Express Scripts. He is the co-author of a study that found that although dose consolidation can save two to three cents per member per month, “that does not add up enough to risk patient and physician dissatisfaction with health plan and PBM intervention.

“Researchers at Pharmaceutical Research and Manufacturers of America [PhRMA] had contacted a Medicaid program, pointing out that the program could lower its overall drug costs if it consolidated doses for certain drugs,” says Delate. “The program contacted Express Scripts to see whether an intervention at the point-of-service level would work.”

Rather than intervening directly at point of service, such as implementing on-screen notices to pharmacists, Express Scripts took what Delate calls a softer approach and sent post-prescription intervention letters to physicians and patients recommending consideration of single dosing for specific medications.

A subsequent Express Scripts study examined cost-effectiveness in light of implementation costs and assessed the rate of consolidation that would have occurred had the physicians not been contacted. Delate and colleagues examined pharmacy claims for more than 500,000 members of a large mid-Atlantic health plan from November 2002 to February 2003. They found that about 9 percent of physicians receiving dose consolidation letters changed their patients’ prescriptions to a once-daily dose. They also found that 4 percent of physicians who were part of a randomly assigned control group that did not receive letters switched their patients to a once-daily dose even without being contacted.

Taking into account program costs, dose consolidation that occurred without an intervention, and members who stopped taking the prescriptions possibly as a result of consolidation, only about .08 percent PMPM drug costs savings was achieved, “too low a rate, we believed, to overcome the concerns of some of the physicians we contacted and rationalize the expense of the intervention,” says Delate.

Not much return

Although the Express Scripts consolidation intervention program did find cost-saving opportunities for some therapy classes — including calcium blockers, antihypertensives and antihyperlipidemics — the researchers found that the number of prescriptions was too small to justify implementing a program for those classes alone. In some other therapy classes with a significant number of prescriptions, such as anti-inflammatories, anti-ulcers drugs, and antidepressants, the cost savings were too small to justify implementing a program because of the availability of generic or over-the-counter (OTC) drugs in the class.

Express Scripts discovered that physicians had several rationales for continuing twice-dosing regimens. For elderly patients, several physicians expressed concern about impaired kidney function and, as a result, preferred lower dosing. For patients on antipsychotics, compliance was an issue. “Some physicians said that their patients were more likely to take at least part of their medications if they had two opportunities a day to remember,” says Delate. Another rationale was that some physicians wanted patients to take their medications with morning and evening meals.


According to Robert Oscar, president of RxEOB in Richmond, Va., which sells pharmacy benefit management software for use in consumer-directed plans, the Express Scripts study highlights the cost-savings limits of what he calls “traditional physician education, mailings, and prior authorization programs.”

“The idea is to lower the cost of programming to encourage dose consolidation when it does make sense,” says Oscar. “Less expensive programs such as Internet-based messaging and emerging e-prescribing support could make dose consolidation cost-effective.”

A study by researchers at Provider Service Network (PSN), a management services company in Boston, found that the types of programs Oscar is referring to can be cost-effective. According to David Calabrese, RPh, director of pharmacy services at PSN, the problem with the Express Scripts research was that the PBM only looked at potential interventions “randomized to either a letter to the physician or a letter to the physician and patient. Sending a letter to a physician, who is not at risk for pharmacy costs, without a recent drug profile, new prescription, or patient letter to sign, would result in poor physician compliance with the requested intervention.”

His company’s approach to dose consolidation is aggressive and demonstrates higher savings. “Our materials are presented to physicians during one-on-one and group educational sessions where the physicians are asked to review the patient-specific request for conversion, indicate whether it is clinically appropriate, and sign the patient letter and new prescription if they are in agreement with the change,” says Calabrese. As a result of this aggressive approach, PSN achieved savings of 5 cents to 9 cents PMPM. PSN states that investment in their dose consolidation program results in a 5:1 return on investment.

Some PBMs and plans do find that dose consolidation programs are cost effective. Cigna Pharmacy Management has used dose consolidation interventions since 2001 for its fully insured members. Cigna contacts physicians recommending that they change to a once-daily dose, but only if the physician deems the change appropriate, says Thom Stambaugh, PharmD, vice president for clinical pharmacy. He adds that physicians are receptive because they believe single dosing improves compliance — although the number of patients switching to a single dose is apparently small.

Medco Health Solutions also uses dose consolidation intervention to save money, says Woody Eisenberg, MD, vice president and chief medical officer of the PBM. “It is most appropriate for drugs with a long half-life.”

70 percent change rate

In 2005, Medco saved its plan sponsors up to 0.3 percent PMPM of total drug spending through dose consolidation, Medco officials report.

Some state Medicaid programs are aggressive in promoting dose consolidation. Wisconsin pays pharmacists to contact physicians and recommend consolidation for a specific list of drugs, mostly antidepressants and antipsychotics.

Kansas reported saving nearly $38,000 in 2005 as the result of dose consolidation.

“There are possible savings. Dose consolidation does work, but we concluded that our clients were just not getting that much out of such a program,” says Delate.

Contributing Editor Martin Sipkoff is a long-time health care journalist.

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