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Appropriate Drug Use and Prescription Drug Programs

Program Design


Patricia J. Byrns, B.S.N., M.D., Associate Professor, Office of Research, Office of the Dean of the School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Steven Wegner, M.D., J.D., President and Medical Director, Access Care, Inc., Morrisville, NC.

Bruce C. Stuart, Ph.D., Parke-Davis Professor of Geriatric Pharmacotherapy, Executive Director Peter Lamy Center on Drug Therapy and Aging, University of Maryland School of Pharmacy, Baltimore, MD.

Steve Wegner explained the course and strategies he used to develop AccessCare into an accessible, cost-effective health care network serving North Carolina Medicaid recipients.

He began by explaining the history of the North Carolina Medicaid program and its core philosophical principles. In a study of the North Carolina Medicaid Benefit conducted in April 2001, the Lewin Group noted that North Carolina is ahead of most other States in offering eligibility to the aged, blind, and disabled up to 100 percent of the Federal poverty level, but consequently the North Carolina Department of Medical Assistance had difficulty controlling its costs. Medicaid payment rates in North Carolina are some of the highest in the country at 100.1 percent of costs.

North Carolina's Medicaid program has developed through several different stages. The first, Carolina Access I, established in 1991 was required to offer benefits such as after-hours consultations, a review of the need for referral services, and authorization of emergency room referrals. In 1998 a more formal network began called Carolina Access II/III. This program operates at two different levels: There is a statewide network of large practices, and countywide partnerships involving physicians' hospitals and health departments.

Access II/III sites are required to:

  • Develop a risk-assessment process.
  • Implement a care management plan.
  • Identify high-cost users.
  • Review emergency department utilization.
  • Implement disease management programs.

In the environment of the Access II/III program, Wegner established the AccessCare network, a statewide, nonprofit network owned by physician groups. The network includes the University of North Carolina, a federally qualified health center, and various practices of about 12 physicians. In total, the network includes 33 practices across the State, treats 107,698 patients, incorporates local care managers, and offers Health Insurance Portability and Accountability Act (HIPAA) compliant, Web-based information to providers.

Due to the rising costs in the North Carolina Medicaid budget, AccessCare sought to evaluate high-quality, cost-containing programs. It began by evaluating the impact of implementing a disease management program for asthma patients. The program study involved educational partners such as the University of North Carolina at Chapel Hill, the Institute for HealthCare Improvement (IHI), and the National Initiative for Children's Healthcare Quality (a division of IHI) to help them better understand how asthma care is provided to children and identify and understand barriers to care. The results of the study revealed that for the calendar year of 1999, 65 percent of Access II/III asthma patients ages 5-20 received appropriate medications, compared with significantly lower levels for fee-for-service and health maintenance organization patients. Similarly, in 2000, Access II/III asthma patients were significantly less likely to be admitted to the hospital than they were in 1999. Compared with other programs, total treatment costs incurred from Access II/III patients, including emergency room visit costs, were significantly lower than those enrolled in Access I or other programs.

While the asthma disease management program saw marked success, the Lewin Group assessment still reported a 25-percent increase in prescription drug costs from 1999 to 2000 and encouraged the State to develop an even stronger pharmacy management program. Given this environment, AccessCare pursued a method of reducing costs by consistently using technology throughout its network. To streamline processes and reduce administrative costs, AccessCare invested in hand-held devices for all of its physicians. These devices:

  • Track drug use pathways.
  • Link to prior authorization and self-authorization systems.
  • Include a preferred drug list.
  • Provide information on true drug costs to educate physicians on the real cost of drugs at the time of prescribing.

Wegner concluded his presentation by showing screens from these devices and demonstrating how they have been extremely effective in the AccessCare system.

Dr. Stuart discussed the importance of tracking the quality of pharmaceutical care at the population level as well as at the individual level. He also touched on:

  • How quality indicators (QIs) are defined and used to monitor prescription drug therapy at the population level.
  • How to apply QIs using the Beers' criteria.
  • How to translate QI findings to improve quality of drug therapy in public programs.

Stuart explained that while most tools to promote appropriate use of pharmaceuticals are focused on a single patient, such as drug utilization review (DUR), prior authorization, and individualized disease management, quality indicators track appropriateness of drug therapy at the population, plan, and organization level. QIs focus on patterns of care and trends in prescribing. Stuart also explained that a good QI will represent an accepted standard of care that is supported by scientific evidence.

Stuart explained that QIs are currently one part of the National Committee for Quality Assurance's (NCQA) Health Plan Employer Data and Information Set (HEDIS®) measures for managed care organizations and assess the use of beta-blockers for post-myocardial infarctions, appropriate drugs for patients with asthma, and antibiotic treatment for otitis media.

Stuart pointed out that using QIs in public programs could provide useful information in answering questions such as:

  • What impact do cuts in Medicaid drug benefits have on quality and access to pharmaceuticals?
  • Are DUR, prior-authorization, and disease management programs effective in improving appropriateness of prescribing?
  • Is quality a problem for particular recipient groups? In particular geographic areas?
  • Is quality and appropriateness of care improving over time?

Stuart explained his research on the application of QI's to elderly Medicare beneficiaries, which sought to:

  • Identify demographic and geographic groups at high risk for inappropriate prescribing.
  • Assess trends in prevalence of inappropriate drug use.
  • Determine if managed care reduces risk of poor prescribing.

His study revealed that of those at risk for receiving drugs with high severity outcomes:

  • Females have 48-percent higher odds than males.
  • White people have 49-percent higher odds than black people.
  • Individuals with incomes less than $10,000 have 43-percent higher odds than those with incomes greater than $30,000.
  • Those in poor health have 92-percent higher odds than those in excellent health.
  • Those taking drugs in more than one therapeutic category have higher odds.
  • 2 categories raised odds by 127 percent.
  • 3 categories raised odds by 331 percent.
  • 4 categories raised odds by 563 percent.

Using a geographic indicator when compared with the East, Stuart recognized that the odds of being prescribed an appropriate drug are 67 percent higher in the Midwest, 83 percent higher in the South, and 45 percent higher in the West. His study also revealed that beneficiaries with part-year benefits had 28 percent higher odds than those with no coverage of being prescribed an inappropriate drug. Those with full-year benefits had the same odds as those with no coverage but had much higher-than-average drug utilization. Finally, Stuart discovered that, despite their higher drug use, Medicare health maintenance organization enrollees had 30-percent lower odds of getting an inappropriate medication than those with no coverage.

Stuart concluded by suggesting that there are many reasons for States to use QIs. He explained that monitoring quality of pharmaceutical care can be beneficial by conducting baseline prevalence estimates of inappropriate prescribing at the program level. It is also important for States to set goals for improved quality of prescribing and identify tangible payoffs to improve performance. States must also remain cognizant of the benefits that will affect the stakeholders and the potential cost savings that QIs can help them achieve.

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