When capitation gets raw, try CHF best practices’
Pharmacists offer optimism, tested strategies
One of the more promising ways to supercede the challenges of capitated pharmacy contracting lies in first going after the "biggie" — congestive heart failure (CHF) — and managing the nation’s most prevalent disease with an eye toward avoiding all too common negative drug interactions among elderly patients.1
That’s the recommendation of William J. Waugh, PharmD, director of disease state management and outcomes research at Wellpoint Pharmacy Management, a part of Wellpoint HMO, both based in Calabasas Hills, CA.
Waugh has tested with success a three-part approach to making a start toward taming the beast of pharmacy capitation. His research team’s common-sense, pharmacy-driven approach offers hope for a healthier quality of life for CHF patients at significantly lower costs. In brief, the three main steps he and his team recommend are:
• Identify Medicare risk enrollees who have a CHF diagnosis.
• Screen (at minimum) for the top 20 most commonly contraindicated drugs in the elderly. (See chart, p. 92.)
• Follow the Agency for Healthcare Research and Quality’s (AHRQ) clinical guidelines for CHF — particularly the drug recommendations.
Waugh’s overall message to insurers is this: "Managed care organizations should be willing to pay for medications if they are going to take on Medicare risk, because that is the most cost-effective." He stops short of recommending physician groups accept pharmacy capitation.
His key worry is that patient medications will be shortchanged. When that happens, overall costs will shoot up, he says. To guard against that threat, a physician group is advised to determine whether a capitated drug plan under consideration is set up to pay adequately for drugs.
The assertion that lowering drug therapies results in higher long-term costs is confirmed in a 1999 study by Robert Popovian, PharmD, senior medical liaison for Pfizer Inc., and his team at the University of Southern California in Los Angeles. In Popovian’s study, primary care patients in the capitated drug plan incurred 14% higher overall costs than patients in noncapitated drug plans.
But his theme rings true for physician practices engaged in Medicare risk contracting, too. One of the best places to start when looking to managed cost issues in a Medicare risk contract is coronary heart disease (CHD), Waugh suggests.
CHD is the nation’s biggest killer. This year, an estimated 1.1 million Americans will have a new or recurrent coronary attack, says the Centers for Disease Control and Prevention in Atlanta. About 650,000 of those will be first attacks, and 450,000 will be recurrent attacks. The patient survival rate is about 60%, and after age 50, the prevalence of CHF doubles with each decade of life.
Given such high rates of heart disease, expenditures for CHF treatment also are high, but they are not uncontrollable, Waugh asserts. Of the $10 billion spent nationally each year on CHF treatment, hospitalization consumes $7 billion, and rehospitalization is a big part of that high price tag. Drugs account for $230 million overall, or about 2.3% of total expenditures.
But improved drug treatment — even if drug costs go up — can significantly reduce hospital admission and readmission costs, Waugh argues. Otherwise, without prevention and optimal drug therapy, CHF cases will only increase as the whopping numbers of baby boomers turn gray.
A three-step approach
Waugh recommends this three-step approach, which he and his team tested among a sample of the HMO’s Medicare risk beneficiaries:
1. Identify Medicare risk enrollees who have a CHF diagnosis. This is done by flagging patients based on prescription records and the ICD-9-CM codes for CHF if hospitalization has occurred. This is where the urgency for insurance coverage starts. Many elderly patients cannot afford to comply with all the drug therapies they need if the drugs are not adequately covered in their plans, he notes. Therefore, their risk for heart failure may not show up in medications records.
2. Screen for the top 20 (at minimum) most commonly contraindicated drugs in the elderly. Even though the threat of drug side effects is well known, patients often are not screened for drugs they are taking to prevent interactions with other new prescriptions, Waugh says.
At one plan he and his team researched, 15% of Medicare risk patients were taking a contraindicated drug. After intervention, drug therapy changes were prescribed for some 70% of the patients in that plan. While end results are not yet available, Waugh expects hospitalizations to be lowered in that plan while quality of life for beneficiaries improves.
3. Follow the AHRQ’s clinical guidelines for CHF — particularly the drug recommendations. The guidelines emphasize appropriate drug use. They recommend use of angiotensin converting enzyme (ACE) inhibitors in all CHF patients and the use of low-intensity warfarin in most atrial fibrillation patients to reduce the incidence of stroke, Waugh explains.
While "firm research" supports the use of ACE inhibitors and warfarin in CHF patients, use has not greatly increased, he says. In Waugh’s study, both drugs were used by less than 40% of the patients in plans managed by Wellpoint’s pharmacy benefits management company, and 20% of patients were not appropriately monitored for warfarin effectiveness. Other research cited by Waugh shows that of patients who need ACE inhibitors, only 40% under primary care physician supervision are prescribed them, and only 70% under the care of specialists are receiving the prescription.
This overall three-step approach for CHF was applied recently to one of Waugh’s assigned plans. While his research is not yet complete, he estimates that hospitalizations will decrease up to 40% within the first year. He also expects that overall patient outcomes will improve and be reflected in the Health Plan Employer Data and Information Set as well as other key performance measures.
Reference
1. Waugh WJ. Managing congestive heart failure in the Medicare risk population. J Man Care Pharm 1999; 5:14-17.
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