GHC OF PUGET SOUND PLANNING CLASS REVIEW OF CALCIUM CHANNEL BLOCKERS; HMO FORMULARIES WILL HAVE DECREASED EMPHASIS ON DRUG COST, MORE ON EFFECTIVENESS

The Group Health Cooperative of Puget Sound is gearing up to conduct a formulary review of calcium channel blockers to prepare for the introduction of new agents into that class. GHC's Pharmacy Director Peter Penna disclosed the upcoming class review at an Oct. 19-21 Group Health Association of America (GHAA) conference in Atlanta. "We will be doing ]a class review[ for calcium channel blockers in the near future because there are several of those that will be coming out," Penna said. FDA has several pending applications for new dosage forms, Marion's Cardizem SR (diltiazem), Pfizer's Procardia GITS (nifedipine), and new chemical entities, such as Miles' BayPress (nitrendipine). Penna pointed out that the GHC Pharmacy and Therapeutics (P&T) committee routinely conducts class reviews of drugs. He explained that "we want to look at an entire class to make sure that what we have is appropriate." Recently the HMO P&T committee engaged in a review of two classes of products, ACE inhibitors and artificial tears. Penna said that antihistamines are reviewed by the committee at least once a year. "When the pressure to add Seldane heats up we will do a review of the entire class again and see what action we want to take," Penna added. Beta Blockers have also recently come under the GHC P&T committee's scrutiny. Penna noted that the committee found that the use of beta blockers is peaking because patients are being switched to newer drugs such as calcium channel blockers and ACE inhibitors. After a review of the therapeutics of the agents in the beta blocker class, the GHC P&T committee determined that propranolol "would be the preferred agent." Justifying the committee's choice, Penna declared, "it has been around for a long time; we know how to use it; we know its limitations." Penna added that "it is also preferred because of its cost, since it is now a generic form." Class reviews will become important as newer, more expensive, but possible more cost-effective drugs come onto the market. "Looking at the drugs that are in the pipeline to be released over the next few years," Penna remarked, "we are going to be looking at more ]expensive drugs[ in the future." Penna noted that the formulary decisions for costly drugs can be tough, even when the drug treats a previously untreatable disease. He cited the ongoing review of Prolastin (alpha-1 antitrypsin). Prolastin, approved late in 1987, is the only currently effective treatment for a rare form of emphysema. The GHC P&T committee, however, has not yet admitted the drug to the HMO's formulary, almost a year after its appearance on the market. The drug costs about $ 20,000 per patient per year. The GHC P&T committee was concerned that even though Prolastin is unique in its class, its efficacy and safety in the long term has not been tested. "We don't know if, in fact, people who use this drug will live any longer," said Penna, and "at $ 20,000 per patient per year, we will not take that decision lightly." The committee will review alpha-1 antitrypsin again in a few months to determine whether the drug should be added to the formulary. United Healthcare Corporation Pharmacy Programs Director Henry Blissenbach told the GHAA group that there will be an "increased emphasis on the comparative effectiveness between drugs," in future formulary decisions. P&T committees will place less "emphasis on overall cost of the product itself." What will increase, he said, is the "emphasis on the drug's ability to decrease hospitalizations" -- on overall outcome measurements. Blissenbach said that formularies will need to "prove effectiveness by outcome measures," including a decrease in per member per month cost. At one level, the HMO should see a decreased frequency rate for prescriptions. "Ultimately," Billenbach said, "the HMO should see "concomitant decreases in medical and hospital services." Maintaining that while newer medications increase the quality and quantity of patients' lives, Bilssenbach said, they also tend to have a significant adverse reaction profile. "This adverse effect profile costs us in the long run, as the medications or therapeutic treatments needed to offset these side effects increases cost to our HMOs," Blissenbach commented. Another goal for formulary management in the future will be increased replacement therapy where single drug therapy could replace multiple drug therapy. "I think we are going to see an increased emphasis on replacement therapy," Blissenbach said. "In other words, the ability to use one drug where three were previously used. This is going to require a fair amount of coordination between our pharmacy department and our practioners." FUTURE OF FORMULARIES The trends below were cited by United Healthcare Corporation Pharmacy Programs Director Henry Blissenbach at a Group Health Association of America conference in Atlanta, Ga. * Increased emphasis on comparative effectiveness * Lesser emphasis on product cost * Increased emphasis on side effect profile * Increased emphasis on replacement therapy * Enhanced enforcement policies