1 Associate Director, Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota.
2 Director, Medical Outcomes Specialist, Global Health & Value, Pfizer, New York, New York.
J Manag Care Spec Pharm. 2016 Feb;22(2):132-44. doi: 10.18553/jmcp.2016.15180. Epub 2015 Dec 14.
Pharmacy cost-saving programs often aim to reduce costs for members and payers by encouraging use of lower-tier or generic medications and lower-cost sales channels. In 2010, a national U.S. health plan began a novel pharmacy program directed at reducing pharmacy expenditures for targeted medications, including pregabalin. The program provided multiple options to avoid higher cost sharing: use mail order pharmacy or switch to a lower-cost alternative medication via mail order or retail. Members who did not choose any option eventually paid the full retail cost of pregabalin.
To evaluate the impact of the pharmacy program on pregabalin and alternative medication use, health care costs, and health care utilization.
This retrospective analysis of claims data included adult commercial health plan members with a retail claim for pregabalin in the first 13 months of the pharmacy program (identification [ID] period: February 1, 2010-February 28, 2011). Members whose benefit plan included the pharmacy program were assigned to the program cohort; all others were assigned to the nonprogram cohort. The program cohort index date was the first retail pregabalin claim during the ID period and after the program start; the nonprogram cohort index date was the first retail pregabalin claim during the ID period. All members were continuously enrolled for 12 months pre- and post-index and had at least 1 inpatient claim or ≥ 2 ambulatory visit claims for a pregabalin-indicated condition. Cohorts were propensity score matched (PSM) 1:1 with logistic regression on demographic and pre-index characteristics, including mail order and pregabalin use, comorbidity, health care costs, and health care utilization. Pregabalin, gabapentin and other alternative medication use, health care costs, and health care utilization were measured. The program cohort was also divided into 2 groups: members who changed to gabapentin post-index and those who did not. A difference-in-differences (DiD) analysis was used to compare the between-cohort change in pregabalin and alternative medication use patterns, health care costs, and health care resource utilization from pre- to post-index. The within-cohort change from pre- to post-index was analyzed by McNemar's test (categorical variables) or paired t-test (continuous variables). The Rao-Scott chi-square test (categorical) and general estimating equations (continuous) were used to analyze between-cohort differences at each time point. Differences in program member characteristics of those who changed versus those who did not change to gabapentin post-index were assessed by traditional chi-square test (categorical) or two-sample t-test (continuous variables).
A total of 1,218 members in each cohort were PSM. Mean age was 51 years, 76.7% were women, and the most common pregabalin-indicated condition was fibromyalgia (77.6%). After the program start, the mean number of pregabalin claims from mail order and retail combined decreased in the program cohort from 4.7 pre-index to 3.8 post-index, and increased in the nonprogram cohort from 4.7 pre-index to 6.2 post-index (DiD, P < 0.001). Pregabalin mail order use increased from 3.1% to 48.1% of program members versus 2.8% to 9.4% of nonprogram members (DiD, P < 0.001). Program members were also more likely to change to the anticonvulsant gabapentin post-index than were nonprogram members (31.0% vs. 15.9%, P < 0.001). Mean total health care costs were similar between cohorts, and the pre- to post-index change did not differ between cohorts (DiD, P = 0.474). However, mean total pharmacy costs rose from pre-index to post-index by $820 and $790 in the program and nonprogram cohorts, respectively (both P < 0.001); the increase was similar between cohorts (DiD, P = 0.888). Program members who changed to gabapentin had a higher mean comorbidity score (P = 0.001) and greater post-index use of opioids, alternative medications, and health care resources (P < 0.050) than program members who did not change to gabapentin.
The pharmacy program increased mail order use of pregabalin but reduced pregabalin claims from any venue. Program members were more likely to change to gabapentin than were nonprogram members, and those who changed had higher comorbidity, use of alternative medication, and health care resources. Despite increased mail order use for pregabalin and greater change to gabapentin by program members, the pharmacy program was not cost saving with respect to mean pharmacy or total health care costs.
药房成本节约计划通常旨在通过鼓励使用较低层次或通用药物和较低成本的销售渠道来降低成员和支付方的成本。2010 年，一家美国全国性健康计划开始实施一项新的药房计划，旨在降低针对特定药物（包括普瑞巴林）的药房支出。该计划提供了多种避免更高成本共付的选择：使用邮购药房或通过邮购或零售切换到成本更低的替代药物。没有选择任何选择的成员最终将支付普瑞巴林的全部零售成本。
评估药房计划对普瑞巴林和替代药物使用、医疗保健成本和医疗保健利用的影响。
这项基于索赔数据的回顾性分析包括在药房计划的前 13 个月（识别[ID]期：2010 年 2 月 1 日至 2011 年 2 月 28 日）期间有普瑞巴林零售索赔的成年商业健康计划成员。符合福利计划包括药房计划的成员被分配到计划队列中；其他所有人都被分配到非计划队列中。计划队列的索引日期是 ID 期内的第一次零售普瑞巴林索赔，且在计划开始后；非计划队列的索引日期是 ID 期内的第一次零售普瑞巴林索赔。所有成员在索引前和索引后均连续 12 个月参保，且至少有 1 次住院索赔或≥2 次针对普瑞巴林指征疾病的门诊就诊索赔。队列通过逻辑回归基于人口统计学和索引前特征进行倾向评分匹配（PSM）1:1，包括邮购和普瑞巴林使用、合并症、医疗保健成本和医疗保健利用。测量了普瑞巴林、加巴喷丁和其他替代药物的使用、医疗保健成本和医疗保健资源利用情况。计划队列还分为两组：索引后改用加巴喷丁的成员和未改用加巴喷丁的成员。采用差异-差异（DiD）分析比较了索引前后两组之间普瑞巴林和替代药物使用模式、医疗保健成本和医疗保健资源利用的变化。通过 McNemar 检验（分类变量）或配对 t 检验（连续变量）分析索引前和索引后的队列内变化。使用 Rao-Scott 卡方检验（分类）和广义估计方程（连续）分析每个时间点的队列间差异。评估了索引后改为加巴喷丁与未改为加巴喷丁的计划成员特征之间的差异，方法是通过传统的卡方检验（分类）或两样本 t 检验（连续变量）。
每个队列中共有 1218 名成员进行了 PSM。平均年龄为 51 岁，76.7%为女性，最常见的普瑞巴林指征疾病是纤维肌痛（77.6%）。计划开始后，计划队列中从邮购和零售渠道获得的普瑞巴林总索赔数量从索引前的 4.7 次减少到索引后的 3.8 次，而非计划队列中从索引前的 4.7 次增加到索引后的 6.2 次（DiD，P < 0.001）。计划队列中普瑞巴林邮购使用从 3.1%增加到 48.1%的成员，而非计划队列中从 2.8%增加到 9.4%的成员（DiD，P < 0.001）。与非计划队列成员相比，计划队列成员更有可能在索引后改用抗惊厥药加巴喷丁（31.0%比 15.9%，P < 0.001）。两个队列的总医疗保健成本相似，索引前后的变化没有差异（DiD，P = 0.474）。然而，计划和非计划队列的总药房成本分别从索引前到索引后增加了 820 美元和 790 美元（均 P < 0.001）；两个队列之间的增加相似（DiD，P = 0.888）。改为加巴喷丁的计划成员的合并症评分更高（P = 0.001），且在索引后使用阿片类药物、替代药物和医疗保健资源的频率更高（P < 0.050）。
药房计划增加了普瑞巴林的邮购使用，但减少了任何渠道的普瑞巴林索赔。与非计划队列成员相比，计划队列成员更有可能改用加巴喷丁，且这些成员的合并症、替代药物使用和医疗保健资源使用更多。尽管计划成员的普瑞巴林邮购使用增加，且改用加巴喷丁的比例更高，但就平均药房或总医疗保健成本而言，药房计划并未节省成本。
