I'm working my way through all of the drug trend reports released within the last week. I plan to provide a general overview of those within the next week or so (lots of data to sort through). I just got through the highlights from ESI, though, and found the approach interesting - and troubling.
The overview I read starts with "2011 Highlights" on page 1. And the overarching theme of the highlights is waste... $2.1 billion worth of waste in work comp. They define waste as "any additional spend on pharmacy costs that provides no incremental gain in health outcomes." Great definition.
But the report goes on to emphasize three major areas where waste occurs:
1) Utilization of high-cost brand medications when lower-cost therapeutic alternatives are available;
2) Not enough use of mail order as a mode of drug delivery (retail is more expensive);
3) Processing of prescriptions through out-of-network pharmacies and third party billers.
Those of you that know PRIUM know that I'm a bit... let's just say "focused"... but what about utilization of prescription drugs that are not medically necessary according to clinical guidelines (guidelines which, in many states, are statutorily recognized)?
Would ESI really have us believe that the way to limit inappropriate use of narcotics and other drugs can be summed up in "generics, mail order, and networks"?
Later in the report, in much smaller font, there's a section on "Narcotics Abuse and Misuse" that at least acknowledges what the CDC has called an "epidemic," but ESI offers no direct solutions. I think there's a simple reason for this: it's complicated to try to solve the problem of prescription drug abuse and misuse.
Across the thousands of reviews PRIUM has conducted over the last few years, we've found that approximately 73% of the drugs we've reviewed are not medically necessary. Granted, there's selection bias here - PRIUM is often brought it when help is clearly needed on a claim. But cut that number in half... or by two-thirds... that's still a big number.
I completely agree with ESI's definition of waste, but I think they've missed a core component of that waste. When it comes to your PBM services, don't settle for reports. Demand solutions. Demand solutions that tackle head-on the issue of medical appropriateness, abuse, and misuse.
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