Towards ‘Values-Based’ formularies: Generic uptake, sustainability and safety. Value of Generics Conference Montreal, P.Q. October 26, 2011. Alan Cassels, University of Victoria. cassels@uvic.ca I am Supported by research grants, contracts related to health reporting and a UVIC research salary The “learning” objectives: • Look at some data on current trends in drug spending • Recount some examples of how people typically receive drugs and drug coverage. • Suggest ways that drug coverage can become more cost-effective, rationale and safe. What do we hear from employees regarding drug coverage? • “If the doctor prescribes it, I must need it and my plan must therefore cover it.” • “Sure, newer drugs are more expensive, but you get what you pay for, right? • “My doctor gives me free samples because he cares about my health and the cost of the drugs.” • “My drugs don’t cost me anything, they’re free. “ Seeking Solutions to the Drug Benefit Cost Crisis* • Most employer-sponsored drug coverage involves no deductible; most provide 80 to 100% coinsurance. • More than half of employers have plans with no formulary (open formulary or few formulary restrictions). • Despite concerns about escalating costs, employers are wearing most of the cost burden. • Employers are looking for new ways to respond to growing prescription drug costs. *survey report my group carried out in 2005 of major employers in Canada about trends in drug benefit cost control. PLAN DESIGN •Co-insurance •Benefit maximums •Drug formularies •Benefit levels What are some of the ways drug plans control costs? COST AVOIDANCE •Wellness programs •Absence management •Education/awareness •Legislative shifting •Benefit formulas COST SHARING •Employee/member contributions •Flex benefits •Health care spending accounts Change the plan design, avoid costs or share costs What are we actually covering? Top Therapeutic Classifications 2009 Avg Cost by Disease colour % Paid 1) Cholesterol disorders $72.60 9.8% 2) Blood pressure $31.66 7.9% 3) Diabetes $51.67 6.8% 4) Depression $45.69 6.7% 5) Ulcers $52.98 6.4% 6) Rheumatoid Arthritis $1,674.60 5.7% 7) Asthma and other Inflammatory Diseases 47.09 5.5% 8) Antibiotics/Anti-infectives $27.56 4.9% 9) Narcotic Analgesics $27.28 3.2% 10) Skin Disorders $34.10 3.0% GREEN PINK YELLOW Top 25* RANK 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 NAME REMICADE INJECTION NEXIUM 40MG TABLET CRESTOR 10MG TABLET HUMIRA 40MG/0.8ML PFS INJ ENBREL 50MG INJECTION PLAVIX 75MG TABLET CRESTOR 20MG TABLET EZETROL 10MG TABLET SYMBICORT 200 TURBUHALER CELEBREX 200MG CAPSULE CIPRALEX 10MG TABLET COPAXONE 20MG/ML PFS CYMBALTA 60MG DR CAPSULE 16 ADVAIR 250UG INHALATION DISKUS SINGULAIR 10MG TABLET NEULASTA 10MG/ML PFS WITH ULTRASAFE NEEDLE GUARD 17 18 NASONEX AQ. NASAL SPRAY 50MCG CRESTOR 5MG TABLET 19 20 21 22 23 24 25 ONE TOUCH ULTRA BLUE TEST STRIP (ON) LYRICA 75MG CAPSULE SPIRIVA 18MCG CAPSULE JANUVIA 100MG TABLET AVONEX PS 30MCG/0.5ML SYR CIPRALEX 20MG TABLET LIPITOR 20MG TABLET SCRIPTS 12,625 355,983 399,830 13,533 12,145 145,387 168,238 142,409 143,506 191,909 139,645 7,655 66,659 DIN COST PAID 54,759,926 34,766,372 34,495,778 28,728,311 25,471,235 18,907,467 18,023,262 15,443,547 15,412,380 12,652,487 12,356,598 12,255,407 11,631,880 COST PER SCRIPT $4,337.42 $97.66 $86.28 $2,122.83 $2,097.26 $130.05 $107.13 $108.45 $107.40 $65.93 $88.49 $1,600.97 $174.50 82,897 80,372 11,213,330 10,332,257 $135.27 $128.56 3,890 10,316,165 $2,651.97 270,974 110,289 9,991,909 9,136,643 $36.87 $82.84 77,488 57,003 72,619 51,548 4,099 79,711 71,644 8,790,169 8,288,399 8,167,883 8,159,687 7,506,267 7,433,866 7,205,873 $113.44 $145.40 $112.48 $158.29 $1,831.24 $93.26 $100.58 * Based on 2009 data from Telus, the pay-direct drug card provider for Sun Life, Great-West Life, Standard Life and other group insurance companies in Canada. The top drugs represent 10,651,541 prescriptions at a cost of $982,676,747 and an average cost per prescription of $92.25. Next top 25 RANK 26 NAME REBIF 44MCG (12MIU) PFS SCRIPTS 3,523 DIN COST PAID 7,174,368 COST PER SCRIPT $2,036.44 27 28 APO-ATORVASTATIN 20MG TABLET LEVEMIR PENFILL 120,089 37,657 7,095,108 6,854,048 $59.08 $182.01 29 TEVA-VENLAFAXINE XR 75MG ER CAPSULE 112,158 6,580,955 $58.68 30 FLOVENT HFA 250MCG INHALER (AEROSOL) 63,547 6,553,955 $103.14 31 32 33 34 35 ADVAIR 500UG INHALATION DISKUS LIPITOR 10MG TABLET ADVAIR 250MCG MD INHALER BOTOX 50U/100U/200U VIAL GLEEVEC 400MG TABLET 33,323 79,872 35,429 8,654 1,507 6,538,657 6,524,926 6,280,752 6,215,217 6,099,776 $196.22 $81.69 $177.28 $718.19 $4,047.63 36 37 STELARA 45MG/0.5ML INJECTION DIOVAN 80MG TABLET 1,141 77,154 5,871,635 5,676,420 $5,146.04 $73.57 38 39 NOVORAPID 100U/ML INSULIN CARTRIDGE MICARDIS 80MG TABLET 56,239 76,465 5,626,102 5,549,471 $100.04 $72.58 40 41 APO-ATORVASTATIN 10MG TABLET CONTOUR TEST STRIP (ON) 115,972 48,856 5,530,186 5,488,058 $47.69 $112.33 42 43 44 45 46 47 48 LANTUS SOLOSTAR 100U/ML PREFILL PEN 5X3ML BIAXIN 500MG XL TABLET NEUPOGEN 300MCG/ML VIAL AVAPRO 150MG TABLET CRESTOR 40MG TABLET COVERSYL 8MG TABLET BETASERON 0.3MG VIAL 37,986 103,797 3,577 72,976 45,109 71,780 2,590 5,427,347 5,391,436 5,379,047 5,369,313 5,251,928 5,236,177 5,189,359 $142.88 $51.94 $1,503.79 $73.58 $116.43 $72.95 $2,003.61 49 PROMETRIUM 100MG CAPSULE 76,357 5,155,094 $67.51 50 FLOVENT HFA 125MCG INHALER (AEROSOL) 99,963 5,072,999 $50.75 51 APO-LANSOPRAZOLE 30MG CAPSULE 104,748 5,063,848 $48.34 Sheila’s got heartburn… • Office Administrator. 34 years old • She has been taking Losec (omeprazole) for years. It works great. • She feels it’s worth every penny of the $112 per month. Her plan is a 20% deductible so her cost is $22 per month; employer pays $90. • What’s wrong with this picture? Sheila’s Story • Has her doctor ever tried her on over-thecounter treatments for heartburn or “older but proven” H2-antagonists? • Does she know her benefit plan pays twice as much as it could/should for her heartburn? • Does she know that PPI users have a higher risk of pneumonia and infection with Cdifficile and that long-term use of PPIs is associated with an increased risk of certain bone fractures? • Many provinces have PPIs under “Special Authority” (prior authorization) so why doesn’t her private drug plan follow? Proton Pump Inhibitors PPIS RANK NAME SCRIPTS DIN COST PAID GENERIC NAME COST PER SCRIPT 86 LOSEC 20MG SR TABLET 31,342 3,526,819 OMEPRAZOLE MAGNESIUM $112.53 72 PANTOLOC 40MG TABLET 46,986 PANTOPRAZOLE SOD 3,968,654 SESQUIHYDRATE $84.46 97 PREVACID 30MG CAPSULE 37,861 3,178,019 LANSOPRAZOLE $83.94 139 RATIO-OMEPRAZOLE 20MG SR TABLET 40,657 2,335,652 OMEPRAZOLE MAGNESIUM $57.45 146 MYLAN-OMEPRAZOLE 20MG DR CAPSULE 39,440 2,234,249 OMEPRAZOLE $56.65 55 APO-OMEPRAZOLE 20MG CAPSULE 92,286 4,949,920 OMEPRAZOLE $53.64 110 NOVO-LANSOPRAZOLE 30MG CAPSULE 59,236 2,901,782 LANSOPRAZOLE $48.99 80 APO-PANTOPRAZOLE 40MG TABLET 77,387 3,765,016 PANTOPRAZOLE SODIUM $48.65 51 APO-LANSOPRAZOLE 30MG CAPSULE 104,748 5,063,848 LANSOPRAZOLE $48.34 187 SANDOZ PANTOPRAZOLE 40MG TABLET 36,953 1,746,831 PANTOPRAZOLE $47.27 193 TEVA-PANTOPRAZOLE 40MG TABLET 36,358 1,705,965 PANTOPRAZOLE SODIUM $46.92 58 RAN-PANTOPRAZOLE 40MG TABLET 102,136 4,667,691 PANTOPRAZOLE SODIUM $45.70 213 TECTA 40MG EC TABLET 42,947 1,588,876 PANTOPRAZOLE MAGNESIUM $37.00 186 RAN-RABEPRAZOLE 20MG EC TABLET 52,009 1,749,680 RABEPRAZOLE SODIUM $33.64 64 TEVA-RABEPRAZOLE EC 20MG TABLET 137,468 4,336,467 RABEPRAZOLE SODIUM $31.55 937,814 47,719,468 $50.88 Proton Pump Inhibitors PPIS RANK NAME SCRIPTS DIN COST PAID GENERIC NAME OMEPRAZOLE 31,342 3,526,819 MAGNESIUM COST PER SCRIPT 86 LOSEC 20MG SR TABLET $112.53 72 PANTOLOC 40MG TABLET 46,986 PANTOPRAZOLE SOD 3,968,654 SESQUIHYDRATE $84.46 97 PREVACID 30MG CAPSULE 37,861 3,178,019 LANSOPRAZOLE $83.94 55 RATIO-OMEPRAZOLE 20MG SR TABLET MYLAN-OMEPRAZOLE 20MG DR CAPSULE APO-OMEPRAZOLE 20MG CAPSULE 110 NOVO-LANSOPRAZOLE 30MG CAPSULE 59,236 2,901,782 LANSOPRAZOLE $48.99 80 APO-PANTOPRAZOLE 40MG TABLET 77,387 3,765,016 PANTOPRAZOLE SODIUM $48.65 51 APO-LANSOPRAZOLE 30MG CAPSULE 104,748 5,063,848 LANSOPRAZOLE $48.34 187 SANDOZ PANTOPRAZOLE 40MG TABLET 36,953 1,746,831 PANTOPRAZOLE $47.27 193 TEVA-PANTOPRAZOLE 40MG TABLET 36,358 1,705,965 PANTOPRAZOLE SODIUM $46.92 58 RAN-PANTOPRAZOLE 40MG TABLET 102,136 4,667,691 PANTOPRAZOLE SODIUM $45.70 213 TECTA 40MG EC TABLET 42,947 1,588,876 PANTOPRAZOLE MAGNESIUM $37.00 186 RAN-RABEPRAZOLE 20MG EC TABLET 52,009 1,749,680 RABEPRAZOLE SODIUM $33.64 64 TEVA-RABEPRAZOLE EC 20MG TABLET 137,468 4,336,467 RABEPRAZOLE SODIUM $31.55 139 146 OMEPRAZOLE 40,657 2,335,652 MAGNESIUM $57.45 39,440 2,234,249 OMEPRAZOLE 92,286 4,949,920 OMEPRAZOLE $56.65 $53.64 937,814 47,719,468 $50.88 PPI Special authority form, BC Pharmacare What is the basis for BC PharmaCare’s “Special Authority” process around PPIs? • Evidence show that all PPIs are equally effective for the treatment of common acid-reflux conditions. • PharmaCare’s first-covered PPI for patients eligible for Special Authority approval was previously rabeprazole (Pariet® and generics). • On January 26, 2010, PharmaCare coverage was expanded for the PPIs, and pantoprazole Mg was added as another first-covered PPI for patients eligible for Special Authority approval. These patients now have two PPI options - rabeprazole and pantoprazole Mg – with one Special Authority approval. • Patients become eligible after first trying ranitidine (Zantac® and generics), cimetidine (Tagamet® and generics), or a similar drug. • Excerpts from Pharmacare memo January 26, 2010 Peter has hypertension… • Retired hospital technician. 74 years old • Told he has “uncontrolled hypertension.” • First drug given to him is a free sample: Diovan (valsartan)—it’s an ARB • It seems to ‘work’. His municipal pension plan covers 80% ($60) of its 75$/ month cost. • “My doctor is great. He gave me the best” • What’s wrong with this picture? Peter’s Story: The reality • Does he know there are many non-drug approaches to treating hypertension; reduced salt diet, etc? • Does his doctor know that free samples are always the newest, most expensive, least studied drug? • Does his doctor know the guidelines saying a drug like Diovan is a 4th line treatment (after a diuretic, an ACEInhibitor and maybe a Beta-blocker)? • Why would his drug plan pay 75$ a month instead of a better treatment costing only $15 per month? • If his plan was guided by similar rules to BC Pharmacare’s formulary rules he’d need to try an ACE-inhibitor first. • The Municipal Pension plan got rid of its dental coverage and may dump its drug coverage. Why? It’s unsustainable. Top drugs for hypertension RANK NAME SCRIPTS DIN COST PAID GENERIC NAME COST PER SCRIPT 37 DIOVAN 80MG TABLET 77,154 5,676,420 VALSARTAN $73.57 39 MICARDIS 80MG TABLET 76,465 5,549,471 TELMISARTAN $72.58 45 AVAPRO 150MG TABLET 72,976 5,369,313 IRBESARTAN $73.58 47 COVERSYL 8MG TABLET 71,780 5,236,177 PERINDOPRIL ERBUMINE $72.95 56 ATACAND 16MG TABLET 62,464 4,949,782 CANDESARTAN CILEXETIL $79.24 65 DIOVAN 160MG TABLET 55,611 4,297,484 VALSARTAN $77.28 67 COVERSYL 4MG TABLET 83,116 4,143,479 PERINDOPRIL ERBUMINE $49.85 70 AVAPRO 300MG TABLET 54,848 4,044,720 IRBESARTAN $73.74 82 ATACAND 8MG TABLET 52,148 3,717,417 CANDESARTAN CILEXETIL $71.29 85 ATACAND PLUS 16/12.5MG TABLET 47,947 3,591,600 CANDESARTAN CILEXETIL/HCTZ $74.91 90 MICARDIS PLUS 80MG/12.5MG TABLET 49,353 3,431,569 TELMISARTAN/HYDROCHLOROTHIAZIDE $69.53 93 APO-RAMIPRIL 10MG CAPSULE 90,943 3,280,945 RAMIPRIL $36.08 98 AVALIDE 300MG/12.5MG TABLET 45,785 3,175,360 IRBESARTAN/HCTZ $69.35 99 DIOVAN-HCT 160/12.5MG TABLET 44,245 3,171,984 VALSARTAN/HCTZ $71.69 111 COZAAR 50MG TABLET 33,517 2,798,256 LOSARTAN POTASSIUM $83.49 127 DIOVAN-HCT 160MG/25MG TABLET 35,047 2,562,292 VALSARTAN/HCTZ $73.11 130 COVERSYL PLUS 4MG/1.25MG TABLET 37,216 2,509,953 PERINDOPRIL ERBUMINE/INDAPAMIDE $67.44 151 COZAAR 100MG TABLET 27,196 2,188,671 LOSARTAN POTASSIUM $80.48 155 TEVA-RAMIPRIL 10MG CAPSULE 55,150 2,150,252 RAMIPRIL $38.99 160 AVALIDE 150MG/12.5MG TABLET 29,351 2,074,953 IRBESARTAN/HCTZ $70.69 170 HYZAAR DS (100MG/25MG) TABLET 27,558 1,984,045 LOSARTAN POTASSIUM/HCTZ $72.00 178 DIOVAN-HCT 80/12.5MG TABLET 27,066 1,881,902 VALSARTAN/HCTZ $69.53 190 AVALIDE 300MG/25MG TABLET 25,264 1,717,448 IRBESARTAN/HCTZ $67.98 191 RAN-RAMIPRIL 10MG CAPSULE 35,952 1,707,648 RAMIPRIL $47.50 219 APO-RAMIPRIL 5MG CAPSULE 59,613 1,514,414 RAMIPRIL $25.40 222 MICARDIS 40MG TABLET 22,540 1,499,432 TELMISARTAN $66.52 1,300,305 84,224,985 $64.77 Top drugs for hypertension RANK NAME SCRIPTS DIN COST PAID GENERIC NAME DIOVAN 80MG TABLET 39 MICARDIS 80MG TABLET 76,465 5,549,471 TELMISARTAN $72.58 45 AVAPRO 150MG TABLET 72,976 5,369,313 IRBESARTAN $73.58 47 COVERSYL 8MG TABLET 71,780 5,236,177 PERINDOPRIL ERBUMINE $72.95 56 ATACAND 16MG TABLET 62,464 4,949,782 CANDESARTAN CILEXETIL $79.24 65 DIOVAN 160MG TABLET 55,611 4,297,484 VALSARTAN $77.28 67 COVERSYL 4MG TABLET 83,116 4,143,479 PERINDOPRIL ERBUMINE $49.85 70 AVAPRO 300MG TABLET 54,848 4,044,720 IRBESARTAN $73.74 82 ATACAND 8MG TABLET 52,148 3,717,417 CANDESARTAN CILEXETIL $71.29 85 ATACAND PLUS 16/12.5MG TABLET 47,947 3,591,600 CANDESARTAN CILEXETIL/HCTZ $74.91 90 MICARDIS PLUS 80MG/12.5MG TABLET 49,353 3,431,569 TELMISARTAN/HYDROCHLOROTHIAZIDE $69.53 93 APO-RAMIPRIL 10MG CAPSULE 90,943 3,280,945 RAMIPRIL $36.08 98 AVALIDE 300MG/12.5MG TABLET 45,785 3,175,360 IRBESARTAN/HCTZ $69.35 99 DIOVAN-HCT 160/12.5MG TABLET 44,245 3,171,984 VALSARTAN/HCTZ $71.69 111 COZAAR 50MG TABLET 33,517 2,798,256 LOSARTAN POTASSIUM $83.49 127 DIOVAN-HCT 160MG/25MG TABLET 35,047 2,562,292 VALSARTAN/HCTZ $73.11 130 COVERSYL PLUS 4MG/1.25MG TABLET 37,216 2,509,953 PERINDOPRIL ERBUMINE/INDAPAMIDE $67.44 151 COZAAR 100MG TABLET 27,196 2,188,671 LOSARTAN POTASSIUM $80.48 155 TEVA-RAMIPRIL 10MG CAPSULE 160 AVALIDE 150MG/12.5MG TABLET 29,351 2,074,953 IRBESARTAN/HCTZ $70.69 170 HYZAAR DS (100MG/25MG) TABLET 27,558 1,984,045 LOSARTAN POTASSIUM/HCTZ $72.00 178 DIOVAN-HCT 80/12.5MG TABLET 27,066 1,881,902 VALSARTAN/HCTZ $69.53 190 AVALIDE 300MG/25MG TABLET 25,264 1,717,448 IRBESARTAN/HCTZ $67.98 219 RAN-RAMIPRIL 10MG CAPSULE APO-RAMIPRIL 5MG CAPSULE 222 MICARDIS 40MG TABLET 191 77,154 5,676,420 VALSARTAN COST PER SCRIPT 37 55,150 2,150,252 RAMIPRIL $73.57 $38.99 35,952 1,707,648 RAMIPRIL $47.50 59,613 1,514,414 RAMIPRIL $25.40 22,540 1,499,432 TELMISARTAN $66.52 Savings if you covered blood pressure pills according to the guidelines? What if the most effective, guideline-approved drug was the one prescribed first? – Diovan: 77,000 prescriptions, total cost $5.6 million. – Generic ramipril: $43 per script would cost $3.3 million – Generic hydrocholorothiazide: $2.45 per script would cost $188,000 Marge has ‘high’ cholesterol • • • • • University sociologist: 54 years old Told she has “high cholesterol”. She asks for a generic; gets generic atorvastatin. It costs 50% of the brand ($50 instead of $100) Needs a ‘boost’ so her doctor gives her a sample of Ezetrol (ezetimibe)$108/ month • “My doctor is great. He really cares about bringing my cholesterol down.” • What’s wrong with this picture? Marge’s Story • Treating “high cholesterol” in women is unproven. • A study released in January 2008 showed ezetimibe had no benefit on the buildup of arterial plaque when compared with patients taking only statins. $108 for no added benefit? • Side effects include: Rhabdomyolysis - severe muscle damage including pain, tenderness, weakness and liver damage. • Marge wonders why she feels weak all the time. Statins: drugs to lower cholesterol RANK NAME SCRIPTS DIN COST PAID GENERIC NAME 5,251,928 ROSUVASTATIN CALCIUM COST PER SCRIPT 46 CRESTOR 40MG TABLET 45,109 $116.43 8 EZETROL 10MG TABLET 142,409 15,443,547 EZETIMIBE $108.45 7 CRESTOR 20MG TABLET 168,238 18,023,262 ROSUVASTATIN CALCIUM $107.13 66 LIPITOR 40MG TABLET 40,018 4,209,578 ATORVASTATIN CALCIUM $105.19 25 LIPITOR 20MG TABLET 71,644 7,205,873 ATORVASTATIN CALCIUM $100.58 232 LIPITOR 80MG TABLET 14,515 1,422,804 ATORVASTATIN CALCIUM $98.02 3 CRESTOR 10MG TABLET 399,830 34,495,778 ROSUVASTATIN CALCIUM $86.28 18 CRESTOR 5MG TABLET 110,289 9,136,643 ROSUVASTATIN CALCIUM $82.84 32 LIPITOR 10MG TABLET 79,872 6,524,926 ATORVASTATIN CALCIUM $81.69 154 LIPIDIL EZ 145MG TABLET 34,986 2,160,978 FENOFIBRATE $61.77 63 APO-ATORVASTATIN 40MG TABLET 73,671 4,383,327 ATORVASTATIN CALCIUM $59.50 27 APO-ATORVASTATIN 20MG TABLET 120,089 7,095,108 ATORVASTATIN CALCIUM $59.08 246 APO-ATORVASTATIN 80MG TABLET 23,730 1,351,439 ATORVASTATIN CALCIUM $56.95 40 APO-ATORVASTATIN 10MG TABLET 115,972 5,530,186 ATORVASTATIN CALCIUM $47.69 1,440,372 122,235,377 $84.86 Statins: drugs to lower cholesterol RANK NAME 46 CRESTOR 40MG TABLET 8 EZETROL 10MG TABLET 7 CRESTOR 20MG TABLET 66 SCRIPTS DIN COST PAID GENERIC NAME 45,109 5,251,928 ROSUVASTATIN CALCIUM 142,409 15,443,547 EZETIMIBE COST PER SCRIPT $116.43 $108.45 168,238 18,023,262 ROSUVASTATIN CALCIUM $107.13 LIPITOR 40MG TABLET 40,018 4,209,578 ATORVASTATIN CALCIUM $105.19 25 LIPITOR 20MG TABLET 71,644 7,205,873 ATORVASTATIN CALCIUM $100.58 232 LIPITOR 80MG TABLET 14,515 1,422,804 ATORVASTATIN CALCIUM $98.02 3 CRESTOR 10MG TABLET 399,830 34,495,778 ROSUVASTATIN CALCIUM $86.28 18 CRESTOR 5MG TABLET 110,289 9,136,643 ROSUVASTATIN CALCIUM $82.84 32 LIPITOR 10MG TABLET 79,872 6,524,926 ATORVASTATIN CALCIUM $81.69 154 LIPIDIL EZ 145MG TABLET 34,986 2,160,978 FENOFIBRATE $61.77 63 APO-ATORVASTATIN 40MG TABLET 73,671 4,383,327 ATORVASTATIN CALCIUM $59.50 27 APO-ATORVASTATIN 20MG TABLET 120,089 7,095,108 ATORVASTATIN CALCIUM $59.08 246 APO-ATORVASTATIN 80MG TABLET 40 APO-ATORVASTATIN 10MG TABLET 23,730 115,972 1,440,372 1,351,439 ATORVASTATIN CALCIUM $56.95 5,530,186 ATORVASTATIN CALCIUM 122,235,377 $47.69 $84.86 What values would a “Values-based” formulary be based on? • Full access to the “best” medications. • Best? – NEWEST – MOST COSTLY – MOST ADVERTISED – MOST SEXY – MOST ADVANCED – MOST TALKED ABOUT 25 What values would a “Values-based” formulary be based on? • Full access to the “best” medications. • Best? – Best in effectiveness – Best in cost effectiveness – Best in safety – Best in terms of a proven track record (no surprises) 26 What these stories tell us? • Free samples are gateway drugs to higher drug spending and poor prescribing. • Private drug plans who “pay for everything” often disregard the concept of comparative cost effectiveness. Employees and employers suffer. • Both employees and employers should avoid a drug plan that provides automatic coverage of: • More expensive drugs vs. less expensive drugs that are equally effective. • Brand names vs. generic drugs which do the same thing. • Newer drugs of unknown benefit vs. older proven therapies. • Drugs of questionable safety vs. drugs whose safety profile we know. 27 “Managing” the formulary. • Needs an independent, high quality source of drug information for payers, patients and prescribers. • Three key elements: prior authorization, generic substitution and therapeutic substitution. • Involves other costs, especially education and communications. • Employees need to be incented to seek value in their prescriptions. “They don’t cost anything, they’re free!” 28 What role do plan sponsors have in educating their members who believe?: • “If the doctor prescribes it, I must need it and my plan must pay for it.” • “Newer drugs are more expensive, but they are always going to be better. You pay for what you get, right?” • “The drugs don’t cost me anything, they’re free.“ Conclusions • ‘Newer’ never automatically mean ‘more effective.’ • Communicating ‘value for money’ to payers, patients and prescribers would help improve rational use of drugs. • Think of drug coverage in terms of “What is it that we value?” 30 How to contact me: Alan Cassels University of Victoria cassels@uvic.ca 250 361 3120