Prime Insights

Pilot study proves value of high-risk medicine interventions for Medicare beneficiaries

Prime Therapeutics | Nov. 25, 2015

Health care spend among U.S. seniors is wildly disproportionate. At 13 percent, those ages 65 and older make up a small segment of the population. Yet they account for more than one-third of all health care costs — spending at a rate three times that of the average working-age person.1

Prescription drug spend makes up a significant part of this spend. Growing drug costs dramatically outpaced overall health care inflation in 2014. And drug costs are expected to continue to rise at a higher rate for the next decade.2

At Prime, managing high-risk medicines (HRMs) for Medicare beneficiaries is an important part of optimizing health outcomes and managing cost across the pharmacy and medical benefit. As age increases, so do risks for drug and drug-disease interactions, leading to a higher rate of hospitalizations, nursing home placements and other adverse events.3

Because of the higher risks and costs, both the Centers for Medicare & Medicaid Services (CMS) and the Healthcare Effectiveness Data and Information Set (HEDIS) have quality measures that focus on decreasing the use of HRMs in the elderly. For plan sponsors, that means HRM prescriptions have a direct impact on Star ratings and related bonuses.

Focusing on timely HRM interventions not only helps Medicare members get the medicine they need to feel better and live well — it can help to manage total health care costs and improve Star ratings.

What we tested
Prime teamed up with a Blue Cross and Blue Shield Plan client and CoverMyMeds, the nations’ largest electronic prior authorization (ePA) platform, to pilot real-time drug safety alerts during the ePA process. These alerts included recommendations for alternative, non-HRM medicines that have similar therapeutic effects.

What we learned
Timely HRM interventions work. Prime’s real-time ePA messaging was applied to 843 HRM prescription requests for adults 65 and older. As a result, these Medicare beneficiaries were 57 percent less likely to receive HRM prescriptions (instead receiving a safer alternative). This pilot, along with a variety of other programs focused on member safety and quality, helped Prime’s plan client achieve a five-star rating for many CMS Star measures.