Drug therapy expenses continue to escalate rather dramatically. From 1992 to 1997, drug costs paid out by either insurers or by capitated provider groups increased by 123%. From the first quarter of 1998 through the first quarter of 1999, the MGPO and the rest of PCHI experienced significant growth in drug therapy expense. The average cost per member per month in January-March 1998 was $25.55 and $22.01 for the MGPO and for PCHI, respectively. During the same timeframe in 1999, costs escalated to $29.12 and $26.05 for the MGPO (14% increase) and for PCHI (18% increase). Figure 1 depicts the cost escalation by class of drug. For clarity, the drug category listing is truncated at 80% of total per member per month costs.

Managed care, by removing the patient from any significant economic burden, has created an ideal circumstance for the pharmaceutical industry. The windfall created by direct-to-consumer advertising is significant and is likely to be with us for a while. While it would desirable to demonstrate offsetting costs elsewhere in the delivery of healthcare, this has not consistently been the case. The reality is that these escalating costs are not associated with any demonstrable offsets elsewhere.

The insurance industry response is entirely predictable and we are currently seeing the first phases of what is likely to be a series of "interventions." The most obvious method of reducing the level of cost escalation is to refuse payment for certain drug classes or drugs within a class. Beginning this fall, all of the major insurers will have restrictive formularies. The restrictions announced to date are likely to become more numerous and, unfortunately, more contradictory over the next several months. In addition, at least one insurer has announced its intentions to establish a three-tiered copayment system, which punishes patients for obtaining certain medications. Patients, now accustomed to nearly free access to very expensive drugs, are likely to be angered and confused over these contractual changes.

Over the next few weeks, all MGPO practices will be receiving a three-colored wall chart detailing the present state of formulary restrictions from all of the major providers and the recommended drugs within a class. The format is a familiar one, with drugs in the "red column" considered being least cost-effective and those in the "green" column considered being the most cost-effective. Clinicians should prescribe drugs listed in the "green" column whenever possible. Unfortunately, there will be times when what we have described as the most cost-effective drug in a class will not be covered by a insurance carrier. This difference is due to insurance company contracting only and usually reflects a rebate supplied by the manufacturer via the pharmacy benefit management company.

Here are a few suggestions which should be applicable for all patients:

• Prescribe generic members of a class of drugs whenever possible. For example, prescribe naproxen sodium or ibuprofen rather than Daypro.
• When prescribing SSRI antidepressants, think about using Celexa (citalopram) as a first-line drug. The majority of patients are managed with about 20mg daily. Celexa is about 25% less expensive than Prozac (fluoxetine). Regardless of which drug is chosen, make certain that you give the drug an adequate trial.
• Topical nasal corticosteroids are the most effective and least costly way to manage patients with allergic rhinitis who cannot tolerate first-generation antihistamines like Chlor-Trimeton. Second-generation antihistamines such as Allegra and Claritin should only be used as third-line drugs for patients with nasal symptoms.
• Lipitor (atorvastatin) is the most effective of the HMG CoA reductase inhibitors and when based on LDL lowering, is the most cost-effective member of the class.
• Patients should not receive more than 3 months of therapy with Prilosec (omeprazole) or any other antiacid therapy unless you have made a definitive endoscopic diagnosis or by Helicobacter pylori serologic testing.

 

Partners Community Healthcare, Inc.
Pharmacy Utilization Management Program
Recommendations from Partners Community Healthcare, Inc.

Therapeutic Class	Lowest Cost Agents	Mid-Cost Agents	Highest Cost Agents
Calcium Channel Blockers	Adalat CC Diltia XT (diltiazem extended release) Diltiazem SR Verapamil SR	Sular Plendil	Procardia XL Cardizem CD Norvasc
ACE Inhibitors	Captopril Univasc Mavik	Lisiopril (Zestril/Prinivil) Accupril Monopril Lotensin	Vasotec
Angiotensin II Receptor Blockers (ARB's)		Atacand Diovan Cozaar	Avapro
HMG-CoA Reductase Inhibitors	Lescol Lipitor	Zocor Pravachol Baycol	Mevacor
H2 Antagonists/Proton Pump Inhibitors	OTC's Cimetidine (generic) Ranitidine (generic)		Zantac Axid Pepcid Prilosec Prevacid
NSAID's	OTC's Naproxen (generic) Ibuprofen (generic)		All brand names
Antibiotics	All generics Erythromycin TMP/SMX (Bactrim) Doxycycline Amoxicillin Penicillin		Ceftin Augmentin Biaxin Zithromax
Asthma       Inhaled Steroids/B-Agonists	Albuteral Inhaler (generic) Vanceril Vanceril DS Pulmicort Azmacort Flovent 44 mcg	Maxair Bronkometer Serevent Flovent 110mcg	Nebulizer Alupent Brethaire Tornulate Flovent 220mcg Aerobid
Leukotriene Antagonists		Singulair Accolate	Zyflo
Allergy Oral and Nasal	OTC (chlorpheniramine 4,8, or 12mg) Allegra Vancenase AQ DS Beconase or Beconase AQ	Allegra-D Semprex D Zyrtec Claritin D Flonase Nasonex Rhinocort NAsacort AQ	Claritin Claritin D Claritin Redi-Tabs Hismanal
Anti-Depressants	Celexa Zoloft	Paxil	Prozac
OCP's	Necon (all dosages) Nelova (all dosages)	Zovia Jenest Levora Desogen Trivora	Ortho-Novum Demulen Nordette Levlen Triphasil Modicon Loestrin