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Benefits and Pensions MonitorEmployees Versus Patients: Does The Same Prescription Apply? Catch-22 Plan sponsors probably feel like they are in a Catch-22 situation. If they reduce access or reimbursement to important maintenance drugs, the health status of their employees may be negatively affected. Asking plan members to pay more of the drug cost might have a detrimental effect if employees stop taking essential medicines. In the case of cholesterol lowering agents, thereʼs a significant drop-off in taking the medicine over the first year. Evidence has shown that up to 70 per cent of statin users stop taking their medicine within the first 12 months of therapy [Brogan Inc., 2005]. This creates an obvious conundrum for employers. If employees stop taking their drugs, their health status is affected, and the employer is then at risk of having an employee experience a significant cardiovascular event. If an employee suffers a heart attack, he or she is absent from work for an extended period of time, goes on disability leave, and returns to work in worse shape than before the event – assuming, of course, that the employee survived the heart attack and wasnʼt permanently disabled. Alternately, an employee that is compliant with his or her statin medicine may not feel any different as a result of the drug which is a reason why increased co-pays can affect patient compliance. In other words, the patient may not feel any different, at least in the short term, as a result of discontinuing therapy. In his regular practice, Dr. Niedoba constantly sees the negative outcomes of poor cardiovascular health. For the general population, advice and direction for good lifestyle habits comes from limited sources, one of them being the family physician. For private drug plans, thereʼs an opportunity to get messaging to employees in the workplace. The manner in which health messages can be relayed can be diverse – health fairs, lunch ʻn learn sessions, bulletin board notices, and intranet postings. However, delivering messages and modifying human behaviour are two different things. One approach to combining the two is to hold screening clinics in the workplace. Success Factors Dr. Niedoba has identified three success factors for cardiovascular health promotion in the workplace:
Identifying patients at risk can be done by holding on-site cardiovascular screening clinics. These should utilize a clinic team of, if possible, a nurse and/or physician. Adding a lifestyle and/or exercise therapist is ideal. For each employee that participates, basic indicators of cardiovascular health can be measured (weight, waist, body mass index, blood pressure, cholesterol, and blood sugar). To have useful measurements, employees should complete a Wellness Inventory Scale that includes existing levels of exercise, stress at work and home, and nutrition. Implementation of an effective, strategic approach starts by identifying important lifestyle changes and, if necessary, the use of medication to achieve cholesterol targets. If possible, the employee is referred to their family physician with appropriate recommendations. Improved patient compliance can be a challenge. As mentioned above, compliance for statins is statistically very poor. Evidence has shown that support programs can improve compliance to a level of around 65 per cent after 12 months instead of 30 per cent without any support [Brogan Inc., 2005]. With the assistance of a manufacturer sponsored support program, a compliance rate of 96 per cent for statins within the period of six to 12 months has been achieved. Cardiovascular Screening First-hand experience with this type of approach for cardiovascular screening has shown that even employees who think they are healthy can have some level of lipid abnormality. When this approach was taken at Husky Injection Moldings last year, 150 employees signed up for a cardiovascular screening clinic and 25 per cent of them required some sort of intervention to address their cardiovascular health status. If screening clinics can help to identify a problem, what can be done to influence or change employee behaviour towards the way they manage their personal health? The answer may lie with the use of a patient support program. One program that Dr. Niedoba has utilized was sponsored by AstraZeneca, the makers of the statin product Crestor. Users have access to free personalized lifestyle coaching through the Crestor Healthy Changes Support Program. This includes access to registered dieticians and exercise specialists. Employees/patients often need motivational support in order to achieve adherence to medications and to lifestyle changes. These changes can endure over time if patients feel that they are in control. However, employee empowerment and responsibility cannot be achieved strictly by a support program. As stated by Dr. Niedoba, “optimal treatment of high cholesterol requires tailoring treatment to the patientʼs individual needs. This means having access to the right drug, the right dose, and adherence to therapy.” Compliance to a treatment regime is enhanced by a comprehensive support program. Therefore, both employers and employees can benefit from support programs sponsored by manufacturers. If we recognize that many patients do not react the same way to the same drug, physicians might need to try different therapies before achieving the desired results. If the optimal outcome is not achieved with the first drug that is given, thereʼs a risk that the patient gets discouraged and de-motivated. In turn, this can affect compliance and commitment to therapy. In the case of statins, thereʼs a medical need to get the patient to target lipid (cholesterol) levels as quickly as possible – not only for medical reasons, but also to keep the patient committed to therapy. If this can be done with the drug of first choice, and done without having the patient re-visit the doctor many times to increase the dosage on a specific brand of drug, then the desired outcomes will come faster and the patient will likely remain on therapy. Plan Design This brings us to another issue that relates to benefits plan designs. If a plan design arbitrarily ties the physician ʼs hands by stating that a specific brand must be utilized first, or alternately, any brand may be tried, but the patient will only be reimbursed to a pre-determined price level (Maximum Allowable Cost), thereʼs the risk of achieving sub-optimal results and, more importantly, the risk of losing the patientʼs commitment to self-health management. A strategic approach to employee wellbeing has to recognize the changing demographics of the workforce. Despite the high costs of some medicines, there are therapeutic areas that require essential treatments for a broad spectrum of employees – cholesterol control is one such area. Not only is the workforce aging, but some high level managers are at an age that requires close attention to health management issues. Itʼs one thing to get them engaged in therapy compliance, but itʼs quite another thing to restrict their access to the best therapies available. For statins, there are medical objectives that physicians try to meet and, in all cases, patient commitment and compliance are essential. From a drug benefit perspective, there are drug costs that plan sponsors want to lower. This article suggests that it can be an acceptable thing to have some high drug costs (preventative medicines such as statins) in order to reduce benefit costs in other areas. On the other side of the equation, some non-productive drug costs can be addressed by improving compliance among patients in order to avoid wastage. From within a workplace setting, Dr. Niedoba has witnessed the effects of having a multi-faceted approach to health management so that plan sponsors can improve employee health and lower overall benefits costs. Access to the right drugs can save money in other areas of the benefits offering … and isnʼt that what itʼs all about? ■
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Gordon Polk is president of Drug Benefit Consulting.