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Executive Summary

PCS' concurrent drug utilization review (DUR) program is saving the prescription drug benefit claims processor an average of 3.9% on total claim costs per client, DUR Director Don Johnson, PhD, told the American Managed Care and Review Association's Sept. 17-18 pharmaceutical conference in Tucson, Ariz. Savings from denied and reversed claims -- i.e., the cost not spent for drugs that otherwise would have been dispensed -- "represent an average of about 4% of the total claims cost for the client," Johnson said. PCS launched its electronic concurrent DUR program last January under the name "Quantum Alert" and calls the program "the first on-line, real-time DUR system in the industry" ("The Pink Sheet" July 16, T&G-11). The program currently serves 44 clients covering more than 500,000 patients, Johnson said. The system allows for interventions at the point of dispensing and looks for problems that "are significant, require real-time attention" and "can be addressed in the on-line environment," he noted. PCS is "processing about 250,000 claims monthly through the DUR program, and this is growing very rapidly." Specifically, the program looks for drug-drug interactions, therapeutic duplications, high drug doses, drug/age conflicts, drug/pregnancy contraindications and excessive utilization, Johnson explained. In October, he noted, the system will be expanded to look for doses that are inappropriately low. The program questions possible overutilization by flagging refills that are dispensed too soon after the previous supply. The system does not apply to supplies of three days or less. For supplies of four to 14 days, it will flag refills presented before 75% of the days have elapsed (e.g., it will flag a refill of a 12-day supply requested on day eight or earlier). For supplies of 15 days or more, the system will question refills requested more than 10 days before the supply is scheduled to run out. Johnson noted that the program applies only to oral dosage forms; other prescription products, such as ointments and lotions, cannot be readily measured in days. One option for the pharmacist receiving an excessive utilization notice is to tell the patient that payment for the refill has been denied; however, Johnson pointed out, the system allows for professional override. Payment will be provided for an early refill if, for example, the patient is planning for travel or has had a purse stolen. To date, the program has flagged far more prescriptions for the possibility of excessive utilization than for any other potential problem. Six thousand Rxs (representing 3.16% of all claims) have been questioned for potentially excessive use, Johnson reported. The system also has flagged 500 Rxs (.24% of claims) for possible drug-drug interactions, 4,300 Rxs (1.45%) as potential therapeutic duplications, 2,300 (0.96%) for high doses, 250 (.10%) for drug-age conflicts, and 1,500 (.78%) for drug-pregnancy contraindications. Almost all alerts to the pharmacist (94.7%) involve a single problem with the prescription, Johnson continued. Furthermore, 4.6% of alerts involve only two potential problems. Prescriptions posing three or more potential problems represent fewer than .7% of claims flagged by the system. Johnson said the challenge of a DUR program is getting pharmacy "practitioners out there to act on the information we find." About 300 prescriptions questioned per month, representing 3%-4% of flagged Rxs, result in a "reversal," he reported, adding that PCS "would like to see this reversal figure go up." A prescription is "reversed" when it is not dispened, Johnson explained, noting that other appropriate responses to a DUR notification include physician monitoring and blood screening. Reversed and denied claims provide monthly savings of$180,000 to $190,000 on average, Johnson reported. However, reversals represent less than $10,000 of the total; claims denied due to potential overutilization constitute the remaining cost savings. The savings for denied and reversed prescription drug claims are running 7.9 times greater than the PCS charge to clients for administering the DUR program, Johnson said. He acknowledged that PCS currently cannot measure actual savings generated by its DUR program. Such a calculation would involve "measuring the actual drug-specific changes in the profile, which occurs as a result of the DUR message [to the pharmacist], and measuring the decrease or increase in the overall cost of the drug regimen following DUR," he said. "This is methodology we're working on, but it's not easy to do."

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