In addition to utilization management tools that are administered at the time of adjudication, plan sponsors increasingly use a variety of intervention programs to promote appropriate use, quality of care, and improved health outcomes. These programs typically intervene with the patient and/or physician after a medication has been dispensed. Thus, they are often retrospective in nature. The effectiveness of these programs can vary greatly across vendors and for some, remains unclear.
Disease management was, by far, the most commonly used clinical/educational program among respondents; however, only 62% of respondents offered disease management in 2011, compared to 74% in 2010. This drop could be due to more recent dissatisfaction with the value proposition of disease management vendors, particularly among larger employers. Disease management programs are sometimes purchased through the PBM, but more often are purchased through the health plan or through a stand-alone disease management company. Half of respondents used a therapeutic substitution program. While the survey did not specify the nature of the program, often these programs involve a letter or phone call to a patient after they have received a medication, making them aware that a lower cost, therapeutic alternative is available. In some cases, the PBM may offer to contact the doctor to request the medication substitution. Use of Retrospective DUR dropped from 57% of respondents in 2010 to 40% in 2011, the reason for which is unclear. Face-to-face consults were used by 39% of respondents, similar to 2010 (41%). Implementation of physician-focused programs was low at 13% for academic detailing and 23% for the less intensive prescriber profiling (Figure 41).
As shown in Table 29, carve-out employers were more likely than carve-ins to implement outbound telephone calls (53% vs 33%; p<.05), retrospective DUR (56% vs. 26%; p<.05), and therapeutic substitution programs (58% vs. 43%; p<.05).
Figures 42 to 46 report the use of these programs by therapy class. Across the five key therapy classes/conditions examined, disease management was the most popular tool with the exception of depression.This is not surprising as disease management for depression is less well-established than for the other conditions. For depression, therapeutic substitution was the most commonly reported program, at 80% of respondents. Generic sampling was more common in asthma (50%) than the other conditions while outbound telephone calls and face-to-face consulting were most common in diabetes. This is expected as medication therapy management programs which involve pharmacist intervention are commonly seen for diabetes.
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