Along with creating an increase in healthcare demand and the subsequent provider issues, PPACA also requires providers to practice evidence-based medicine, apply care coordination, discuss preventative health for at risk populations and “follow up” with individuals. Much has been made of the evidence-based medicine requirement, which many feel may be hard to implement. The main implementation problem is the lack of clear scientific evidence for diagnosis algorithms or “the art” of how practicing providers judge appropriate therapies for individual patients.
For the pharmaceutical industry, evidence-based medicine will mean more data/evidence needs to be supplied from pharma that the practicing provider can use with the branded product. Conversely, the evidence-based requirement is shared by multi-source products to be used as therapeutic tools by the provider. For branded products with minimal clinical differentiation from older therapies, it will hasten the need for comparative effectiveness.
Comparative effectiveness aside, for the commercial side of pharma the dilemma with having an evidence-based medicine requirement is how to deal with currently marketed or near to market products. Increased phase IV studies may help but often they don’t seem to meet the formulary committee’s desire for real world evidence. This increased push towards evidence-based medicine and comparative effectiveness will push brand marketing even further into the scientific message using most of the already time-constrained sales call.
With PPACA, the push towards more care coordination and preventative health discussions will directly impact the providers’ daily activity. These new efforts will push increased non-pharma content into a provider’s individual patient cycle. An increased emphasis on care coordination requires the comprehensive storage of all patient healthcare information. Such information is then shared and discussed across the spectrum of healthcare providers a patient may be consulting. To conduct this type of inclusive reporting and decision making, the providers’ office must increase time allocated to each patient on a daily basis in order to adequately manage these critically important processes.
In addition to care coordination, providers are being pressured to increase individual patient discussion regarding prevention. Currently, and increasingly in the future, the only way the provider can increase the prevention discussions with their patients is by melding preventive medical advice into already tight face time with patients or off-load the requirement to an affiliated healthcare provider in the office. Either way, the change will put more strain on how quickly the office can cycle a patient through, which impedes its ability to generate revenue and handle the new healthcare demand.
PPACA’s inclusion of millions of new patients as well as the new coordination and prevention steps put significant strain on the individual patient cycle in the provider’s office. The already strained “face to face” or consult time between the patient and provider is a very critical part of the patient cycle for pharma.
For years the industry has relied on providers to communicate such topics as support programs. The increased pressure from PPACA to ensure care coordination and convey prevention messages will decrease the ability of physicians to discuss third-party information such as brand programs. Needless to say, the implementation of PPACA in 2013 will drive a tremendous time constraint on providers to discuss the prescribed therapy and marketers’ need to understand that constraint or risk alienating the provider audience. The consultation constraints will minimize patient awareness of brand programs at a time when marketers and marketing consultants are placing increased emphasis on the use of support programs to differentiate brands.1 Marketers should assume that brand support programs’ communications will be a low priority in that critical face time consultation and look for alternative avenues to communicate the brand program messages.
Medication Therapy Management
If the clinician will have less time to discuss brand initiatives such as adherence or loyalty programs, where will that discussion go? The answer seems to be spelled out in PPACA as “follow up.” Under PPACA, clinicians will be incentivized to follow up with patients. How follow up will be accomplished is not defined. Also, the follow up initiative incorporates pharmacists. In PPACA the reimbursements for Medication Therapy Management (MTM) sessions by pharmacists are being increased. Some retail pharmacists already see MTMs as another way to generate future revenues as evidenced by the increased requests for support program information from manufacturers.2
The discussion requires Pharmacy Benefit Managers (PBMs) to institute MTM programs using qualified pharmacists for all Medicare part D patients. An MTM is an annual comprehensive medication review furnished face-to-face or using telehealth technologies by a licensed pharmacist or other qualified provider. The comprehensive medication review is supposed to include an overview of the individual’s medications and results in a written or printed summary of the results of the review provided to the patient. As a result of the medication review, a recommended medication action plan in consultation with the individual and with input from the prescriber may be put into place. Of note, PBMs are supposed to assess patients who are at risk but not enrolled in the MTM program at least once a quarter.
So how does PPACA’s “follow up” and “MTM” affect the patient journey? Some may say it is simply a shift from one provider to another. However, experience shows that as change occurs, information is inevitably lost or not conveyed. The problem in changing support program delivery to the pharmacy is the potential increase in “leakage” from the generated prescriptions. Well before any PPACA changes, studies by the National Association of Chain Drug Stores (NACDS) found that less than 70% of prescriptions generated in the provider’s office make it to a pharmacy to be filled. This study has been confirmed several times over the past few years with the most recent being from the Kaiser family foundation using e-prescribing. As marketers know, even when the patient fills the prescription and moves along the patient journey through treatment, there is tremendous non-adherence.
Look for Part Three in the August issue.
1. Case D, IBM’s Reinvention Should Inspire Flat Pharma Business, Forbes, 28 July 2012; http://www.forbes.com/sites/davechase/2012/07/28/ibms-reinvention-should-inspire-flat-pharma-businesses/
2. Manhattan Research, Taking the Pulse Pharmacists, 5 Nov 2012