Smarter scripts

MGMA Connexion, Sep 2005 by Coyle-Toerner, Pam

Case study: Financial benefits of a generic prescription program

When economic incentives between physicians and patients align, change can happen rapidly. We at Queen City Physicians (QCP) proved that providing physicians with the right tools can help control pharmaceutical spending.

QCP, a primary-care group practice in Cincinnati, has eight locations and 34 providers. In 2004, we implemented a prescription program with incentives for prescribing generics. Eligible physician groups must fill at least 50 percent of their prescriptions with generic drugs. The program rewards physicians by increasing a group's fee schedule X percent for every Y points it increases its generic-drug prescribing for participating pharmacy-benefit enrollees.

Generic medications cost a fraction of their brand-name equivalents. Patients taking generics can see sizable savings on their annual copayments. For example, the average annual co-pay for a generic angiotensin-coverting-enzyme (ACE) inhibitor is $144. The brand-name ACE inhibitor's average copay is $540.

QCP garnered support from a prescription provider partner because our generic prescribing percentage was 50.05 percent, compared with the region's average of less than 45 percent.1 We get higher reimbursement from the payer by increasing our generic-prescribing percentage; QCP has received more than $100,000 in revenue as a result of this program. We also had the senior leadership and physician commitment to implement and support new initiatives.

Our program needed buy-in from the top for success. I and our president and senior ranking physician at QCP enthusiastically support the concept.

Keys to success

Claims information must be accurate, complete and current - To increase the efficiency of the process, claim data should include:

* Drug prescribed;

* Patient's name and date of birth;

* Prescribing physician;

* Retail or mail-order pharmacy where prescription was last filled;

* Date it was last filled; and

* Number of refills outstanding and dispense-as-written (DAW) status.

The pharmacy-benefit company provides this information to the group in a spreadsheet.

The team must commit to check for current opportunities - Pharmaceutical representatives do not rush to physicians' offices to inform them when a successful and costly brand becomes available in generic form. Scanning a prescription drug database weekly for generic opportunities, the pharmacy-benefit company forwards the information to QCP providers participating in the initiative.

Physicians must support the generic message - Physicians' buy-in is critical to patients' willingness to accept generic equivalents. QCP added a generic-advantage message to the back of its preprinted prescription paper (see box). All printed prescriptions leaving QCP's internal medicine offices reinforce the physicians' personal message.

Physicians need a way to identify generic opportunities when prescribing QCP's leaders presented a plan for the approval of its physicians, who agreed to revamp the prescription formularies' short lists in our electronic medical record (EMR) to identify generic substitutes. QCP updates these lists as new generics are identified.

Existing refill management an additional opportunity

As we identified generic drug opportunities, the pharmacy-benefits manager provided QCP with a list of patients taking brand-name drugs and their generic counterparts. By reviewing these opportunities with their DAW status, QCP management asked primary care physicians for permission to contact patients to invite them to try a generic for their next refill - emphasizing the cost savings.

QCP has streamlined this process further by assigning practice employees to review the lists and share this information with patients' physicians to determine if generic substitutions are clinically appropriate. With a physician's approval, a medical assistant calls the patient to describe the opportunity. Most patients have reacted positively to the process.

Know your hurdles

Implementing a generic prescription program without an EMR would be difficult. An EMR allows an organization to seize opportunities that traditional paper environments may not support.

Physician commitment is crucial. If your physicians aren't dedicated to the cause, the program most likely won't succeed. QCP's physicians allowed their EMR short lists to be structured to make prescribing a brand-name drugs more difficult - requiring more clicks. Physicians must understand the reason for making them work harder to prescribe brand-name prescriptions - and the reward for prescribing generics.

Patients' lack of awareness of generics can pose another obstacle to the program's success. Physicians must reassure patients that brand-name medications and AB-rated generics are the same.2 While physicians may make the pitch with participating pharmacy-benefit patients, they may not spend the additional time to tell patients not participating in the generic program.

The outcome

Initial results have been dramatic: