Show Me the Evidence Ensuring Access to Safe

Show Me the Evidence Ensuring Access to Safe, Effective and Affordable Prescription Drugs (image from http: //www. deskpicture. com/DPs/Nature/Autumn/Fall. Scene_1. html) Ann L. Woloson, Executive Director Jennifer Reck, Policy Analyst Prescription Policy Choices 2011 International Symposium on Safe Medicine October 4, Portland, Maine

Prescription Policy Choices (PPC) l 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 l 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 l l 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 l l 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 2000 s, 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 l ACA: – – – l 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 generics

Pharmaceutical Industry Marketing l Industry marketing in 2009 – $10. 9 billion l $6. 6 billion direct to physicians; l $4. 3 billion direct to consumers (Kaiser Family Foundation) l In Maine: – – $68 million in 2007 $90. 6 million in 2008

Evidenced-based Drugs: Three Points for Impact Prescribers 1. – Academic detailing/prescriber education (counters drug reps in prescriber’s offices) Consumers 2. – Consumer Reports Health Best Buy Drugs™ / Consumer component to academic detailing (counters direct to consumer advertising) Payers 3. – 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: l Acetaminophen, NSAIDS, opiates and opiate like agents, anticonvulsants and antidepressants l Comparative safety, efficacy and costs of pain medications l Attenuating the risks of adverse events from pain medications l 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 l 80 drug ads every hour, every day on TV (Nielsen Co. ) l 30% of people have spoken to their doctors about a drug ad; 44% got the prescription they asked about (Kaiser Family Foundation) l l 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 costeffective (tried and true)

www. CRBest. Buy. Drugs. org. Reports Drugs to treat high cholesterol: The Statins / Drugs to treat hepatitis C Drugs to treat rheumatoid arthritis/ Migraine Headache Drugs – the Triptans Drugs to Treat Enlarged Prostate / Osteoarthritis, Pain – the NSAIDs Drugs to Treat Muscle Spasms and Spasticity: Muscle Relaxants Drugs to Treat Nausea and Vomiting: The Oral 5 -HT 3 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 Blockers High Blood Pressure, Heart Failure – the ACE Inhibitors Heart Disease and High Blood Pressure – Beta-Blockers Treating Type 2 Diabetes – the Oral Diabetes Drugs Constipation Drugs / Menopause – Hormones/ Sleeping Pills for Insomnia Treating Chronic Pain – the Opioids Treating Bipolar Disorder, Nerve Pain and Fibromalagia – the Anticonvulsants Treating Heart Disease, Heart Attack, and Stroke – Antiplatelets Overactive Bladder / Asthma and Lung Disease – Inhaled Steroids Alzheimer’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 l Compare to Web. MD Magazine l – – includes many advertisements sponsored sections are not reviewed by the Web. MD Editorial Department for accuracy, objectivity or balance

Payers: Lewin Group Study (12/2010) l Identified $30 billion in state savings over the next decade beyond rebates – Savings associated with improved pharmacy benefit management from Medicaid managed care organizations l l 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 yield 14. 8% savings for pharmacy spending ($14 mil for ME)

Payers: Minnesota Study* l l 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 l 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 l l 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 l l 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? l l Are states using evidence based information? How are States integrating evidenced based information into Rx drug coverage decision making processes?

Payers l l 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