The Finite Healthcare Dollar and Infinite Ways to Waste - $9,500 acne cream, anyone?

Mon, 09/26/2016 - 10:45 -- MaxorPlus

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Both pharmaceutical manufacturers and pharmacy benefit managers (PBMs) have come under scrutiny lately.  Manufacturers are accused of excessively increasing prices for existing drugs, and PBMs are accused of being the middle man responsible for reaping profits from these price increases while the consumer and employer, amongst others, are left “holding the bag.”

So why would I recently leave a leadership role in one of the top pharmacies in the country to work for a PBM?  It is simple.

It starts with the fact that a PBM is the single entity controlling how claims from pharmacies are processed and ultimately paid for by employers, patients and other healthcare constituents. 

Why is this so important?

There are dozens of answers to this question, but let’s focus on just three:

  1. Some physicians are influenced to prescribe medications without regard to cost and quality.
  2. Patients whose health depends on proper medication adherence tend to lose focus over time and become non-adherent.
  3. Some patients attempting to abuse the system seek treatment from multiple prescribers and multiple pharmacies – especially for narcotics.

Having direct control over claims processing gives PBMs like Maxor every opportunity to prevent wasteful healthcare expenditures in all three of these and many other areas.  However, few PBMs seem to be taking advantage of their capabilities to truly make a difference in health care. 

So – why did I decide to work for Maxor National Pharmacy Services and MaxorPlus, our PBM?  One reason is that there is no other place where I can apply knowledge of where healthcare waste occurs and have the ability to directly do something about it.

  1. MaxorPlus has prevented payment for drugs that we feel have limited clinical value for years. 
    • Not a single Aloquin prescription (the ~$10,000 acne cream in the headlines recently) has been filled by a Maxor beneficiary since its succession of price increases began in 2015 and ultimately raised the price approximately 40x.
    • When I look at our rejected claims data, I see it is littered with millions of dollars of claims for similar expensive drugs we call “designer generics.” 
    • We have these drugs programmed to reject at pharmacies to prevent wasteful costs and subsequently guide the patient and physician towards more cost-effective alternatives.
  2. Maxor can use our utilization data to stratify diabetic, cardiovascular, specialty, and other patient populations in order to identify and work more closely with individual patients that are not achieving adherence goals.
    • We use this information to determine which patients would likely benefit the most from additional adherence efforts - including heightened communications to physicians and patients.  Many patients don’t realize the number of days of therapy they are missing until they see it on paper and have a discussion with a clinical professional.
  3. Maxor uses a similar stratification approach to narcotic overutilization to validate medical necessity of patients using multiple physicians, pharmacies and high quantities of narcotics.  We can prevent claims payment until we receive more information from the physician and pharmacy to assure legitimacy and medical necessity of the narcotic prescriptions.
    • More than 40 Americans die each day from opioid-related overdoses according to the Centers for Disease Control – PBMs must play their part in addressing this issue.

The reality is our health care system is complex.  Choosing between spending $10,000 on an acne cream (one with limited scientific evidence of efficacy at that!) vs. $10,000 for an oncology drug that may allow a patient to live a normal life is a ridiculous proposition.  Yet, someone out there in the United States is paying for the acne cream, and probably wondering why their pharmacy spend is out of control. 

I just know that “someone” is not a MaxorPlus client.

Mike Einodshofer

Chief Innovation Officer

Maxor National Pharmacy Services, LLC

meinodshofer@maxor.com

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