By Christopher Guadagnino, Ph.D.
Eric Culley, Pharm.D., MBA, is manager of clinical pharmacy services at Highmark Inc.
PND: Could you describe Highmark’s generic drug vending machine program?
EC: We partner with a company called MedVantx which provides the generic sampling machine – a stand-alone unit in physician offices, about the size of a bank ATM machine, which houses approximately 30 to 35 generic drugs. The goal of the program is to have high quality generic medications readily available to be given as samples to Highmark members at their primary care physicians’ office. Whenever a physician wants to give a sample to a patient, they have a mechanism by which they can scan the patient chart, pick whatever drug they want out of the machine and the member will be given a full course of therapy. In some cases, as with antibiotics, the drugs will only be sampled for seven to ten days. If it’s a long-term medication, for example, for high blood pressure, they could get a 30-day supply. The drug is given to the patient, along with a patient package insert with written instructions on how to take the drug, and benefits and side effects – the same type of information typically given at a retail pharmacy. There’s no charge to the physician to have this machine in their office and there’s no co-pay for our members who receive those samples.
PND: How did you select the types of drugs to include in the machines?
EC: It is standard across the machines. MedVantx has sample centers in multiple states in the Northeast, the Midwest and also in California. The system is a multi-payor model, and there are other health plans that participate, including UPMC Health Plan and Coventry. Right now, Highmark is the largest participant and we also have the largest sample volume for our membership. Participants have a voice in what generics are included, and we want to make sure that there’s enough flexibility that the machine is valuable for most primary care physicians, but primarily that is governed by the vendor, MedVantx. They are typically low-cost medications that are widely prescribed for major disease states such as blood pressure and depression.
PND: Regarding Highmark’s participation, how many physicians are involved and where are they located?
EC: They are located throughout western and central Pennsylvania. In 2006 we had 631 physicians, and this year there are around 700 physicians participating in western and central Pa., from approximately 186 practices.
PND: How do you choose which practices participate?
EC: We want to make sure that the practice sees a critical mass of Highmark members and we also look at the overall volume of drugs that a particular office prescribes. They need to be writing a fair number of prescriptions, and also have a representative Highmark population.
PND: Does Highmark offer this program to prospective physician offices, or can physicians request it?
EC: We’ve had both. This program started as a pilot in 10 physician offices. One of my staff, who is a pharmacist and a full-time employee of Highmark, went out to them with the vendor to pitch the program, trying to make sure it was valuable to those physicians. We now have a list of physicians who are interested in participating and we’re trying to get them into the program.
PND: What results has the program produced?
EC: We did a return on investment analysis that was published in the June 2007 Journal of Managed Care Pharmacy. We looked at our overall pharmacy claims. The amount saved per physician was relatively small, but when you look at changing utilization patterns – that’s really where the savings come from. Say their brand prescribing rate was around 50 percent – so half of their scripts were generic and half were brand – we would track and trend that over time and find that our physicians that were in the program had a significantly higher generic dispensing percentage than those in the network and those of their peers. The end result of the study is that having the sample center did change prescribing habits. They used generics more often, and it was financially advantageous for the member because they didn’t have a co-pay. Because generic co-pays are less than brands, long-term savings for the member was there, as it was for the plan and ultimately their employer groups. In 2005 we estimated the cost saving was $397,000, and in 2006 it was $453,000.
Again, there’s no cost to the doctor, there’s no cost to the member, but Highmark is still paying for the generic samples much like we would pay for a generic prescription in a pharmacy. We wanted to make sure that it still made sense financially for us and for our groups – the people paying for insurance. We continue to do a return on investment analysis every year. There’s been a three-to-one, or three-and-a-half-to-one ROI over the last couple of years, and that’s been pretty consistent, so we believe that there is financial value to our members and to our groups. As far as physicians from whom we’ve heard anecdotal feedback, they really like it. It is an alternative to a brand sample closet and many physicians buy into the fact that generics are still high-quality medication. Many of their patients like it because they’re walking out of the office with something in their hand, much like they would be given a brand sample starter pack. With this program, you can walk away with a month’s worth of therapy.
PND: Were there any data as to whether the frequency of prescribing itself changed – for example, physicians who may not have prescribed antibiotics did so because the drugs were readily available at no charge?
EC: That exact study is in peer-review right now. And what we found: the shortest answer to that is no. The overall prescribing didn’t increase more than that of their peers. For the physicians that had this in their office, their increases were the same. We did a second follow-up study on antibiotics for that reason. We were clinically concerned by having antibiotic samples in there and we wanted to make sure that people who would not otherwise have been prescribed an antibiotic didn’t get one, for example for a cold or for a flu, just because there were samples available. Our study, which hopefully will get published, showed that that really did not happen, and it was very encouraging.
PND: What are your plans for expanding the program?
EC: We wanted to make sure that all of our high-volume prescribers who were interested have a machine. The next step is to expand the program to those offices who are perhaps in the middle tier, who don’t prescribe as often but there’s still some opportunity. We’ve been working with our vendor to get more machines in the central Pa. area – Harrisburg, Camp Hill and regions north and south of that – and any other untapped markets in western Pa. as well. We have an ongoing analysis to make sure that we have these machines distributed appropriately.
PND: Are there any plans to expand into the southeastern Pa. region under the aegis of Highmark Blue Shield?
EC: Not in the immediate future. We’re looking at the markets that we understand and do very well in right now – and that’s western and central Pa.
PND: What are the advantages of increasing generic drug use, and what are the barriers?
EC: Whenever people talk about generics, I think we – the pharmacy and medical community – have done ourselves a disservice by calling them generics because it has a negative connotation and the public and sometimes physicians and pharmacists may perceive an inferior quality product. As a physician, you know there are drug reps in your office frequently, and often times there are large sample closets with brand-name drugs in the office. When you have the generic drug machine that competes in that same space, I think that’s been a real inroad for us in breaking down that barrier. What people tend to forget is that these are the same products that were multi-million dollar brand-name agents just five, sometimes ten years ago. They still work. The human body hasn’t changed that much in the last 100 years. They’re high-quality medications. The FDA has very rigorous manufacturing standards around these to make sure that what’s on the bottle is exactly what’s in that tablet. Just because they’ve lost their patent and are no longer marketed by pharmaceutical companies doesn’t mean that the drugs are less effective. They’re great alternatives and they are less expensive. The goal of health insurance, and certainly Highmark, is to keep health care affordable because we know that people who don’t have health care coverage don’t take their drugs and don’t see their physician. If cost is a barrier, generics are a great way to remove that barrier. It’s less expensive for the individual patient. It’s less expensive for the health plan. It’s less expensive for the employer. So in my mind, that’s really a win-win-win.
PND: What are other methods of increasing generic drug use?
EC: Benefit design is probably the intervention with the greatest impact. Generics are typically much less expensive. Generic copays can range from five to ten dollars, or less, versus typical brand-name copays that are $20 to $40 or more. So, there’s a financial incentive to encourage patients to seek out that treatment if it’s appropriate, especially since these are typically monthly medications. We’ve also done analysis and have seen market share shift from several other interventions. We have two counter-detailers – pharmacists who are out in the field promoting the value of generics, and who visit physicians in western and central Pa. as part of our pay-for-performance program, which uses a generic dispensing percentage measure to help give incentives to physicians who use high-quality, low-cost generics. They also visit the offices that have the generic sampling machines, as well as other offices. We have tip sheets on average costs because there are some physicians who don’t know the real cost of drugs. We can analyze particular offices and see what their top ten drugs have been and our pharmacists will sit down with them and go over that profile and show them where there’s opportunity. We also do direct mailings to our membership, for example, when a blockbuster drug becomes generically available. One that comes to mind is Zocor, for high cholesterol. We identified that as an opportunity for anyone who was on a branded statin. We sent them a letter saying that these are alternatives which may or may not be right for you, go talk to your physician. Direct mailings have been encouraged by a lot of our employer groups, because they certainly have a financial stake in the game as well.