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Reducing Patient Drug Acquisition Costs Can
lion per year,1 and health insurance expen-
Concerned about rising prevalence and costs of
ditures for the individual with diabetes are
diabetes among its employees, Pitney Bowes Inc
triple those of the average consumer.2 From
recently revamped its drug benefit design to syner-
the US employers’ perspective, the burden of
gize with ongoing efforts in its disease management
diabetes extends even further to include the
and patient education programs. Specifically, based
$40-billion annual cost for indirect expendi-
on a predictive model showing that low medication
tures because of disability, work loss, and
adherence was linked to subsequent increases in
premature mortality.1,3,4 In fact, disease-
healthcare costs in patients with diabetes, the com-
pany shifted all diabetes drugs and devices from tier
account for about one third of the total cost
2 or 3 formulary status to tier 1. The rationale wasthat reducing patient out-of-pocket costs would elim-
inate financial barriers to preventive care, and there-
Fortunately, investing in aggressive dia-
by increase adherence, reduce costly complications,
betes control not only improves blood glucose
and slow the overall rate of rising healthcare costs.
levels but reduces medical complications and
This single change in pharmaceutical benefit design
costs6-8 and may also boost productivity and
immediately made critical brand-name drugs avail-
lower absenteeism.3,9,10 Although optimized
able to most Pitney Bowes employees and their cov-
use of medications is essential to improved
ered dependents for 10% coinsurance, the same
diabetes control,9 the trend in pharmaceuti-
coinsurance level as for generic drugs, versus the pre-
cal benefit design has been to pass higher
vious cost share of 25% to 50%. After 2 to 3 years,preliminary results in plan participants with diabetes
portions of drug costs to members to slow the
indicate that medication possession rates have
growth of the healthcare budget. But employ-
increased significantly, use of fixed-combination
drugs has increased (possibly related to easier adher-
ence), average total pharmacy costs have decreased
with the desire to increase access to optimal
by 7%, and emergency department visits have
care for costly conditions like diabetes.11 If
decreased by 26%. Hospital admission rates,
although increasing slightly, remain below the demo-
and coinsurance may become a financial bar-
graphically adjusted Medstat benchmark. Overall
rier to proper diabetes care. The short-term
direct healthcare costs per plan participant with dia-
savings may actually impede the opportunity
betes decreased by 6%. In addition, the rate of
for longer-term health budget savings and
increase in overall per-plan-participant health costsat Pitney Bowes has slowed markedly, with net per-
plan-participant costs in 2003 at about $4000 per
year versus $6500 for the industry benchmark. This
recent moderation in overall corporate health costs
may be related to these strategic changes in drug
benefit design for diabetes, asthma, and hypertension
and also to ongoing enhancements in the company’s
disease management and wellness programs.
(Am J Manag Care. 2005;11:S170-S176)
per-participant cost of approximately$3300 per year remained well below the
Direct medical costs for diabetes and benchmark average, the double-digit
increase was cause for alarm. Some of the
and Prevention estimates the cost at $92 bil-
companies cutting back on utilization man-
Reducing Patient Drug Acquisition Costs Can Lower Diabetes Health Claims
Health Insurance Portability and Account-
chronic medical conditions. Perhaps relat-
additional fact that more extremely high-
design. About 80% of plan participants opt for
cost (>$100 000) cases of end-stage long-
a self-insured plan. There are 46 local and
term disease were being treated. But these
were only guesses about the real sources of
carriers and 4 national preferred provider
organizations. In all of the self-funded plans
and a few of the others, the drug benefits are
ny’s concerns led it to tap its own consider-
able information resources to identify its
true cost drivers for several long-term dis-
90% of all employees under 1 common phar-
eases. After evaluating these drivers, man-
maceutical plan provides a potentially pow-
agement then altered its prescription drug
erful single point of entry for studying—and
plan in an attempt to boost plan participant
for leveraging—long-term disease outcomes
access to medications required for the treat-
ment of key chronic conditions such as asth-
are the logical solution for measuring and
ma, diabetes, and hypertension. Key findings
manipulating health in areas such as asth-
related to diabetes are presented in this
ma, cardiovascular disease, and diabetes.
report because the details of employer-initi-
Although disease management is part of the
ated efforts may be relevant to any health-
integrated effort of long-term disease care at
care manager dealing with rising costs for
remain a condition for bidding on companybusiness—the presence of close to 50 sepa-
The Opportunity at Pitney Bowes
rate health plan vendors precluded any easy
opportunity to have an impact on diabetes
care with a single employer-driven program
management systems services and solutions,
has 35 000 employees worldwide and a rev-
duced an Internet-based health portal for
enue of $5 billion per year. Within the United
employees and an opt-in voluntary disease
States, the company’s 23 000 employees are
58% male with an average age of 41 years and
an average length of service of 8.1 years.
more long-term disease awareness and treat-
Twenty-five percent of employees are locat-
Connecticut tristate area, with wide dispersal
helped form a broad base of a sensible bene-
limiting total costs. Still, company manage-
wellness, and disability strategy with data-
bases providing timely feedback on each.
change health behaviors and limit costs.
For example, cost data are available on all
Specifically, they wanted to get ahead of the
cost curve by quickly shifting more plan par-
expenditures. Also available for scrutiny are
ticipants with expensive long-term diseases
In this situation, the drug benefit design
suggested itself as a logical tool for employ-
information, and selected survey results. All
potential value of this common denominator
data are available in aggregated, deidentified
of employee health became even more strik-
ing after the company’s health benefits man-
agers realized, as discussed next, that low
linked directly to next-year per-patient costs
database are 2 quite different experiences.
As described next, this stark evidence of
The Predictive Model:
nonadherence as a cost driver led to ques-
What Causes High-cost Claims?
Shortly after the 13% cost surge of 2000,
cost sharing, price elasticity, and drug acces-
sibility in the Pitney Bowes prescription
caused plan participants to migrate from“normal-cost” ($400-$700 per year) to “high-
Redesigning the Pharmacy Benefits
cost” status (>$10 000 per year). A consulting
The drug plan at Pitney Bowes is not dis-
(recently acquired by LifeMasters Supported
similar from that used by many other large
SelfCare, Inc) worked with Pitney Bowes to
develop a hybrid artificial intelligence pro-
Regular Rx Plan and the “buy-up” Extra Rx
gram that defined the end point in question—
Plan with a slightly lower coinsurance and
in this case, the transition to high costs—and
copays, and an annual out-of-pocket maxi-
then identified the population-level variables
mum of $500 (Table 1
). About 1 of every 4
associated with that end point. The program
was unique in the way that it scoured the
plan is built on a traditional 3-tier formulary
database for any employee variable linked to
but has several consumer-centric elements,
increased costs—not just the preconceived
including limited prior authorization (only 6
variables such as age, concomitant disease, or
drugs require it, all because of safety con-
hemoglobin A1C level. Notably, the predictive
cerns) and no policies calling for mandatory
model also considered the total cost of care
generics, step therapy, or therapeutic substi-
for employees, including not only direct med-
tution. Overall, the plan achieves a 75%/25%
ical costs, such as medical claims, pharmacy,
cost sharing with employees and is consid-
and behavioral health, but also indirect costs
ered to be performing well in terms of stan-
related to absenteeism and disability. The
database and cost assumptions for the pre-
11% rate of mail service prescriptions, an
dictive modeling were set up and are still
overall 48% generic drug utilization, and a
generic drug fill efficiency rate of 91%.
relationship between long-term conditions
for participants with diabetes, asthma, or
and future high total healthcare costs. A key
actionable finding was that illness burden
brand-name medications at the tier 1 rates
and costs were driven by a lack of pharma-
(eg, 10% coinsurance) and thus reducing a
ceutical adherence. In diabetes, those plan
potential barrier to care for long-term dis-
participants with 9 or fewer 30-day prescrip-
ease (Figure 1
). These changes were initi-
tion fills for their diabetic medications were
ated despite the inevitable financial loss
most likely to transition into the high-cost
group. In other words, the patients with dia-
betes who were refilling their insulin and
oral medications only two thirds of the time
or less were likely to become the costliest.
Similar findings were identified for asthma
eliminate a potential reason that employees
and hypertension. Again, lack of adherence
to treatment has been known for decades to
contribute to diabetes complications.12,13 But
reading about nonadherence in a dry journal
Reducing Patient Drug Acquisition Costs Can Lower Diabetes Health Claims
Overview of Pitney Bowes Prescription Drug Plan Design
Coinsurance or Copayment Amount
Regular Rx plan
Regular Rx plan
Rx indicates prescription; HMO, health maintenance organization.
Note: Members in the HMO plans were provided prescription drug coverage through the HMO plan (ie, drugs carved in). However, in2003, members in the HMO plans no longer had prescription drug coverage through the HMO plan (ie, drugs carved out). In 2001, therewere 656 members in 42 different HMO plan options who had a condition of interest—more than 40% of the total eligible populationwere included in the study.
But will it? There is ample literature to
made about the relative efficacies of these
support the concept that excessive copays
agents, the weight of clinical evidence or
cause suboptimal use of essential medica-
value-based arguments supporting their use,
tions.11,14,15 One recent study, for example,
found that doubling the copay for diabetes
any test strips that were in tier 2 or 3 (eg,
drugs led to a 23% decrease in per-member
per-year drug days supplied.15 The American
shifted to tier 1. Although the company was
Diabetes Association also warns explicitly
also enhancing its diabetes disease manage-
about the short-sightedness of erecting cost
ment and wellness efforts in parallel with
barriers to diabetes medications (see Side-
, “Tight Cost Controls May Be Barrier to
Diabetes Management”).12 Still, the actual
return on investment from lowered copays is
less well documented and would, anyway,
Tight Cost Controls May Be Barrier to
company to company. Thus, the polestar for
“Though it can seem appropriate for controls to
this effort at Pitney Bowes remains the inter-
restrict perceived items of convenience in chronic
nal company evidence linking low prescrip-
disease management, particularly with a complex dis-
tion fill rates to high subsequent costs.
order such as diabetes, it should be recognized that
adherence is a major barrier to achieving targets. Any
change involved moving a number of tier 2
controls should take into account the huge burden of
and 3 drugs to tier 1. These included insulin
intensive insulin management on patients, particularly
in the management of type 1 diabetes. Protections
Lantus, Novolin, and NovoLog as well as oral
should ensure that patients with diabetes can comply
agents such as Actos (pioglitazone), Amaryl
with therapy in the widely variable circumstances
encountered in daily life. These protections should
Avandamet (rosiglitazone/metformin), Glu-
guarantee access to an acceptable range and all classes
of antidiabetic medications, equipment, and supplies.”
Glucovance (glyburide/metformin), Prandin
—American Diabetes Association, 20051
(repaglinide), Precose (acarbose), andStarlix (nateglinide). No judgments were
Prescription Drug Access Benefit Design
Prescription Drug Access Benefit
Prescription Drug Access Benefit
Printed with permission from The Benfield Group.
example, glucometers were supplied free of
charge to employees with diabetes—the truly
results in the 2- to 3-year period after the
novel element within this evolving integrated
change have also been promising. As tracked
approach was the new benefit design.
by Caremark Inc, Pitney Bowes’ pharmacybenefits manager, rates of adherence with all
Results in Diabetes: Better Adherence,
medications that shifted tiers increased sig-
nificantly. Perhaps most important, the per-
For the typical plan participant with dia-
betes, the formulary change had the imme-
adherence with insulins decreased by fully
average cost of a 30-day fill dropping by
than their previous drug costs—ie, a 10%
particularly high for these individuals tak-
Reducing Patient Drug Acquisition Costs Can Lower Diabetes Health Claims
insulin-dependent diabetic plan partici-pants, the shift to newer brands of test strips
Pharmacy Costs Per Active Member Per Month for
in tier 1 was associated with a doubling in
the usage rate of these test strips on glu-cometers (from 28% usage to 55% usage).
Naturally, the company’s pharmacy costs
for the insulin, insulin stimulators, insulin
sensitizers, and test strips increased during
this time. But the surprise was that although
the company’s total annual pharmacy costs
per covered person showed a mild increase,
pharmacy costs for those with diabetes actu-
ally decreased by 7%. This overall decrease in
pharmacy costs for employees with diabetes
was thought to result from a reduction in
complications and the avoided need for other
even more expensive drugs. Further detailsof this shift will be explored in a subsequent
PMPM indicates per member per month.
analysis. In fact, the most recent data showthat total per-member, per-month pharmacycost increases for all participants in the
increases of 12% to 15% for benchmark com-
Pitney Bowes active pharmacy benefits plan
panies. Especially in light of the relatively
have remained relatively stable, with annual
increases in the low double-digits, over the
changes were implemented, this moderation
past 3 years (Figure 2
) despite the extra
extremely promising. Based on these prelim-
medications for 3 major long-term diseases.
inary findings, the healthcare team at Pitney
Medical utilization and costs for plan par-
Bowes continues to track results—including
between 2001 and 2003. The rate of ED vis-
costs, another potential contributor to the
company bottom line—and to consider sim-
further distanced itself from the benchmark
ilar access-driven benefit changes in addi-
rate (Table 2
). Although it cannot be proved
tional long-term disease categories.
in this setting, this sharp decrease in ED vis-its is likely related to improved adherencewith the oral hypoglycemia medications.
Diabetes-related Utilization for Pitney Bowes
The hospitalization rate increased slightly in
Plan Participants Before (2001) and After (2003)
participants with diabetes, a potential result
of the aging of the workforce. But note thatthis rate also remained below the demo-
rived from the Medstat database. Overall,
Diabetes ED Visits (per 1000 members)
the per-patient cost of care for Pitney Bowes
plan participants with diabetes decreased by
of care for diabetes (and for asthma, for
Diabetes Hospital Admissions (per 1000 members)
which reductions were also seen) likely con-
tributed to the encouraging overall trend in
net per-employee medical direct costs. As
shown in Figure 3
, the average annual
increase in employee health cost from 2000
*Benchmark provided by Thomson Medstat.
Net Per-employee Healthcare Costs: Pitney Bowes
1. Centers for Disease Control and Prevention.
diabetes fact sheet. Available online at: www.cdc.gov/
diabetes/pubs/estimates.htm. Accessed April 21, 2005.
2. Peele PB, Lave JR, Songer TJ.
Diabetes in employer-
sponsored health insurance. Diabetes Care.
3. Ng YC, Jacobs P, Johnson JA.
associated with diabetes in the US. Diabetes Care.
4. Mayfield JA, Deb P, Whitecotton L.
and diabetes. Diabetes Care.
5. Ramsey S, Summers KH, Leong SA, Birnbaum HG,
Kemner JE, Greenberg P.
Productivity and medical costs
of diabetes in a large employer population. Diabetes
6. The Diabetes Control and Complications Trial
The effect of intensive treatment of
diabetes on the development and progression of long-
term complications in insulin-dependent diabetes melli-
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
tus. N Engl J Med.
1993;329:977-986.7. UK Prospective Diabetes Study (UKPDS) Group.
Intensive blood-glucose control with sulphonylureas or
*All values for both Pitney Bowes and the benchmark are derived from the
insulin compared with conventional treatment and risk
of complications in patients with type 2 diabetes
(UKPDS 33). Lancet.
1998;352:837-853.8. Gilmer TP, O’Connor PJ, Manning WG, Rush WA.
The cost to health plans of poor glycemic control.Diabetes Care.
1997;20:1847-1853.9. Testa MA, Simonson DC.
Health economic benefits
and quality of life during improved glycemic control in
Sharp increases in diabetes prevalence at
patients with type 2 diabetes mellitus: a randomized, con-trolled, double-blind trial. JAMA.
Pitney Bowes during the past few years—
10. Rizzo JA, Abbott TA 3rd, Pashko S.
tivity effects of prescribed medicines for chronically ill
workers. Health Econ.
11. Karter AJ, Stevens MR, Herman WH, et al;
Translating Research Into Action for Diabetes Study
Out-of-pocket costs and diabetes preventive serv-
ices: the Translating Research Into Action for Diabetes
and as the workforce continues to age, the
(TRIAD) study. Diabetes Care.
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12. American Diabetes Association.
bursement for diabetes care, self-management education,
diovascular care will build. As indicated
and supplies. Diabetes Care.
13. Pladevall M, Williams LK, Potts LA, Divine G, Xi H,
Clinical outcomes and adherence to medica-
tions measured by claims data in patients with diabetes.
limit overall costs for diabetes by selec-
14. Huskamp HA, Deverka PA, Epstein AM, Epstein RS,
McGuigan KA, Frank RG.
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formularies on prescription-drug utilization and spend-ing. N Engl J Med.
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benefits and the use of drugs by the chronically ill.
Biogene Amine in Lebensmitteln und Biogene Amin-Intoleranz 1. Gliederung 1. Gliederung.1 2. Definition von biogenen Aminen.1 3. Vorkommen und Entstehung von biogenen Aminen.1 4. Wirkung von biogenen Aminen.1 4.1. Entstehung von Biogener Amin-Intoleranz .1 4.2. Biogene Amin-Intoleranz und Medikamente .1 5. Mögliche Ursachen für eine Überbelastung mit biogenen Aminen
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