Comparison of real-world clinical and economic outcomes in patients receiving oral anticoagulants: A retrospective claims analysis.

BACKGROUND: Direct oral anticoagulants (DOACs) have become widely used for the prevention of stroke in nonvalvular atrial fibrillation (AF) and for the treatment of venous thromboembolism (VTE). Warfarin, the standard of care prior to DOACs, requires monitoring and dose adjustment to ensure patients remain appropriately anticoagulated. DOACs do not require monitoring but are significantly more expensive. We sought to examine real-world effectiveness and costs of DOACs and warfarin in patients with AF and VTE. OBJECTIVE: To examine clinical and economic outcomes. The clinical objectives were to determine the bleeding and thrombotic event rates associated with DOACs vs warfarin. The economic objectives were to determine the cost associated with these events, as well as the all-cause medical and pharmacy costs associated with DOACs vs warfarin. METHODS: This analysis was an observational, propensity-matched comparison of retrospective medical and pharmacy claims data for members enrolled in an integrated health plan between October 1, 2015, and September 30, 2020. Members who were older than 18 years of age with at least 1 30-day supply of warfarin or a DOAC filled within 30 days of a new diagnosis of VTE or nonvalvular AF were eligible for the analysis. Cox hazard ratios were used to compare differences in clinical outcomes, where paired t-tests were used to evaluate economic outcomes. RESULTS: After matching, there were 893 patients in each group. Among matched members, warfarin was associated with increased risk of nonmajor bleeds relative to apixaban (hazard ratio [HR] = 1.526; P = 0.0048) and increased risk of pulmonary embolism relative to both DOACs (apixaban: HR = 1.941 [P = 0.0328]; rivaroxaban: HR = 1.833 [P = 0.0489]). No statistically significant difference was observed in hospitalizations or in length of stay between warfarin and either DOAC. The difference-in-difference (DID) in total costs of care per member per month for apixaban and rivaroxaban relative to warfarin were $801.64 (P = 0.0178) and $534.23 (P = 0.0998) more, respectively. DID in VTE-related cost for apixaban was $177.09 less, relative to warfarin (P = 0.0098). DID in all-cause pharmacy costs for apixaban and rivaroxaban relative to warfarin were $342.47 (P < 0.0001) and $386.42 (P < 0.001) more, respectively. CONCLUSIONS: Warfarin use was associated with a significant decrease in total cost of care despite a significant increase in VTE-related costs vs apixaban. Warfarin was also associated with a significant increase in other nonmajor bleeds relative to apixaban, as well as a significant increase in pulmonary embolism relative to both DOACs. Warfarin was associated with a significant reduction in all-cause pharmacy cost compared with either DOAC. DISCLOSURES: The authors of this study have nothing to disclose.

Estimated cost savings associated with the transfer of office-administered specialty pharmaceuticals to a specialty pharmacy provider in a Medical Injectable Drug program.

BACKGROUND: A large managed care organization (MCO) in western Pennsylvania initiated a Medical Injectable Drug (MID) program in 2002 that transferred a specific subset of specialty drugs from physician reimbursement under the traditional "buy-and-bill" model in the medical benefit to MCO purchase from a specialty pharmacy provider (SPP) that supplied physician offices with the MIDs. The MID program was initiated with 4 drugs in 2002 (palivizumab and 3 hyaluronate products/derivatives) growing to more than 50 drugs by 2007-2008. OBJECTIVE: To (a) describe the MID program as a method to manage the cost and delivery of this subset of specialty drugs, and (b) estimate the MID program cost savings in 2007 and 2008 in an MCO with approximately 4.6 million members. METHODS: Cost savings generated by the MID program were calculated by comparing the total actual expenditure (plan cost plus member cost) on medications included in the MID program for calendar years 2007 and 2008 with the total estimated expenditure that would have been paid to physicians during the same time period for the same medication if reimbursement had been made using HCPCS (J code) billing under the physician "buy-and-bill" reimbursement rates. RESULTS: For the approximately 50 drugs in the MID program in 2007 and 2008, the drug cost savings in 2007 were estimated to be $15.5 million (18.2%) or $290 per claim ($0.28 per member per month [PMPM]) and about $13 million (12.7%) or $201 per claim ($0.23 PMPM) in 2008. Although 28% of MID claims continued to be billed by physicians using J codes in 2007 and 22% in 2008, all claims for MIDs were limited to the SPP reimbursement rates. CONCLUSION: This MID program was associated with health plan cost savings of approximately $28.5 million over 2 years, achieved by the transfer of about 50 physician-administered injectable pharmaceuticals from reimbursement to physicians to reimbursement to a single SPP and payment of physician claims for MIDs at the SPP reimbursement rates.

Longitudinal analysis of the costs associated with inpatient initiation and subsequent outpatient continuation of proton pump inhibitor therapy for stress ulcer prophylaxis in a large managed care organization.

BACKGROUND: Proton pump inhibitor (PPI) therapy is commonly initiatedin hospitals for a variety of reasons including stress ulcer prophylaxis. Outpatient use of inpatient-initiated PPI use may be medically unwarranted. OBJECTIVE: To (a) describe in a longitudinal analysis the incidence and reasons for hospital initiation of PPI therapy, (b) identify the proportion of members continued on PPI therapy at hospital discharge that is not medically warranted, and (c) estimate the total costs incurred by the managed care organization (MCO) and its members due to inappropriate continuation of hospital-initiated PPI therapy after discharge. METHODS: A retrospective review of de-identified medical and pharmacy claims was performed to identify commercial and Medicare patients with an acute care hospital admission and subsequent discharge on a PPI from January 1, 2003, through December 31, 2006, in an MCO with approximately 2.5 million members with medical and prescription drug coverage. Hospital-initiated PPI therapy was assumed based on the presence of a paid pharmacy claim for a PPI within the 30-day period following hospital discharge. All patients who during the study period had (a) no PPI claims during the 90 days prior to an inpatient admission, followed by (b) a hospital stay, and (c) at least 1 pharmacy claim for a PPI during 30 post-discharge days were included in this analysis. Patients with PPI claims during the 90 days prior to their inpatient admission were excluded from analysis as this use was assumed to be appropriate. Any member (a) initiated on PPI therapy during hospital admission without a medically appropriate diagnosis, either primary or secondary, 3 months prior to or during hospitalization and (b) continuing therapy after discharge, as determined by at least 1 pharmacy claim for a PPI during the first 30 post-discharge days, was categorized as an inappropriate user. For the sample subgroup with inappropriate PPI use, costs due to inappropriate PPI therapy were calculated as the total cost incurred by the MCO and its members-including ingredient cost, dispensing fees, member copayments, and coinsurance-for PPI claims during the first 30 days after hospital discharge. RESULTS: Of 29,348 study-eligible members, 68.8% (n = 20,197) were prescribed a PPI inappropriately at hospital discharge. Rates of inappropriate PPI use were approximately equal for patients who stayed in the intensive care unit or coronary care unit (ICU/CCU) versus non-ICU/CCU patients (68.7% vs. 68.9%, respectively, P = 0.796 using the Pearson chi-square test). Over the 4-year period of this analysis, the total cost to the MCO and its members associated with inappropriate continuation of PPI therapy during the first 30 days after hospital discharge was $3,013,069. CONCLUSION: Increased health care costs associated with the utilization of PPIs can result from the inappropriate prescribing and continuation of PPI therapy after hospital discharge. Education of health care practitioners regarding medication reconciliation in general, and regarding continuation of PPI therapy specifically, is needed to increase responsible postdischarge medication utilization.

Case study of the effects of office-based generic drug sampling on antibiotic drug costs and first-line antibiotic prescribing ratios.

BACKGROUND: Health plans and members benefit from the substitution of lower-cost drug therapies that achieve the same clinical outcomes as higher-cost drugs. Previous research suggests that generic sampling programs produce drug cost savings overall, but the effects attributable to acute therapies are unknown. Encouraging physicians to prescribe less expensive, first-line antibiotics may help reduce direct drug costs associated with prescribing potentially unnecessary, and more expensive, second-line agents. OBJECTIVES: To determine the effects of an automated, office-based generic drug sampling kiosk on (a) prescribing of first-line oral antibiotic agents as a ratio of total antibiotic prescribing and (b) average antibiotic drug cost per claim. METHODS: This managed care organization of 2.3 million members with pharmacy benefits collaborated with a vendor that developed an automated generic drug kiosk that allows for the dispensing of samples of generic medications within the prescriber's office. Among the samples contained in the kiosk were 6 generic, first-line oral antibiotics, representing 8 unique drug-strength options. Drug costs were defined as the ingredient cost of the drug claim, which includes plan cost, member cost share, and any dispensing fees or administrative program costs associated with the sampling program. In a difference-in-difference analysis, changes in outcome measures (antibiotic drug cost per claim and dispensing rates of first-line antibiotics) from 2003 (baseline year) to 2005 (post-implementation year) were compared among kiosk prescribers (n=179) and nonkiosk prescribers who were part of the same provider network (n=7,236). A cross-sectional analysis of the same outcome measures compared kiosk (n=396) and nonkiosk prescribers (n=10,267) in 2006. All statistical analyses were performed using t-tests of logtransformed data. RESULTS: The mean cost per claim dropped by $4.14 (12.3%) from $33.56 in 2003 to $29.42 in 2005 for the kiosk prescribers and by $3.35 (8.8%) from $38.26 in 2003 to $34.91 in 2005 for nonkiosk prescribers, but the mean change from 2003 to 2005 in the difference-in-difference analysis was not statistically significant (P=0.123). The first-line antibiotic prescribing ratio declined by 2.1 absolute points from 49.1% in 2003 to 47.0% in 2005 for the kiosk prescribers and by 3.4 points from 46.0% in 2003 to 42.6% in 2005 for the nonkiosk prescribers, but the difference- in-difference analysis showed that the change was not statistically significant (P=0.901). A cross-sectional analysis of 2006 data revealed significant differences between the kiosk prescribers versus their nonkiosk network counterparts for both first-line antibiotic prescribing rates (42.0% and 41.4%, respectively; P=0.028) and antibiotic cost per claim ($28.44 and $32.40, respectively; P<0.001). While the results of the cross-sectional analysis are statistically significant, the practical significance of the results is less evident. CONCLUSIONS: The benefits of including short-term medications such as first-line antibiotics in a generic drug sampling program are difficult to quantify, and the cost outcomes are unlikely on their own to justify generic drug sampling. However, acute (short-term) medications may be an effective part of an overall program to promote generic prescribing for all conditions.

Effects of a physician office generic drug sampling system on generic dispensing ratios and drug costs in a large managed care organization.

BACKGROUND: Greater use of generic drugs, particularly as measured by the generic utilization or dispensing ratio (GDR), is an effective means of managing care by attaining the same clinical outcome as brand drugs but at lower cost. Health plans encourage members to use generic drugs through copayments that are lower than for brand drugs. Encouraging physicians to prescribe generic drugs in therapeutic selection continues to be an opportunity for health plans to produce drug cost savings without compromising safety or efficacy. OBJECTIVE: To determine if the addition of an automated generic drug sampling system in primary care physician offices would increase (1) the GDR of the sampled therapeutic categories and (2) the overall GDR. METHODS: To encourage prescribers to increase their use of generic pharmaceuticals, this managed care organization of 2.3 million members with pharmacy benefits, who represent about two thirds of approximately 3.5 million total health plan members, collaborated with a vendor that developed an automated generic medication sampling intervention that takes place in the physician's office at the point of care. The generic sampling system (kiosk) included 21 distinct generic drugs in 36 variations of dose and strength. To isolate the effect of the generic sampling intervention from the general trend of greater generic drug use, we compared physicians participating in the generic sampling program with all other network physicians. Because formal statistical testing of program outcomes was precluded by incomplete physician data, we performed a descriptive, business-case analysis of the program. RESULTS: Before implementation of the generic sampling program, the physicians in the intervention group and the comparison group had the same GDR of 47.8%. In the first full year of the intervention in 2005, the 301 physicians participating in the generic sampling program had a GDR of 55.3% compared with 54.1% for all of the other approximately 33,000 network physicians. This absolute 1.2 percentage point difference narrowed to 0.8 points in 2006 (59.9% vs. 59.1%). After subtraction of payments made to the vendor of the generic samples, including all administrative costs, the direct drug cost savings were estimated to be $397,486 in 2005 and $453,545 in 2006. The direct drug cost savings per physician participating in the generic sampling program were estimated at $1,321 in 2005 and $719 in 2006. Members paid no copayment for the generic samples and paid lower copayments throughout the continued use of the generic drugs for chronic conditions such as hypertension. CONCLUSIONS: Physician practices that participated in the generic sampling program demonstrated an increase in the average GDR that was slightly greater than the increase in the comparison group of all other network physicians in each of the 2 measurement years, 2005 and 2006. Direct drug cost savings after subtraction of all administrative costs associated with the generic sampling program were estimated at $1,321 per participating physician in 2005 and $719 per participating physician in 2006. Members benefited from no copayment for the generic drug samples and from lower copayments for continued use of the generic drugs.