Improving Transplant Care Outcomes

For transplant patients, the difference between a successful and an unsuccessful outcome can be made by medication adherence.

Medication adherence has a significant impact on whether care is effective or ineffective. According to the Annals of Internal Medicine, the cost of medication nonadherence may reach up to $289 billion each year, making it one of the largest single sources of waste in the medical system.

Medication nonadherence is particularly important in organ transplantation because patients need powerful drugs to overcome the body’s natural resistance to the transplanted heart, liver, or kidney. Yet even though anti-rejection drugs are essential, studies have consistently shown that nonadherence in the transplant population ranges from 20% to 70%, depending on how it is measured. It is clear that there is room for effective new ways to help transplant patients manage their postoperative therapy and care more successfully.

Keeping patients adherent to their posttransplant anti-rejection medication regimens was a key focus of the study published by OptumRx and UnitedHealthcare in the Journal of Managed Care Pharmacy entitled “Managing Specialty Medication Services Through a Specialty Pharmacy Program: The Case of Oral Renal Transplant Immunosuppressant Medications.”

THE SOLUTION

Anti-rejection medication nonadherence is one of the leading causes of transplant rejection and multiple adverse clinical effects, including renewed need for dialysis, additional sickness, and mortality. Nonadherence has many causes. For example, patients may misunderstand the importance of their anti-rejection drugs or they may not understand when and how to take their medications. Side effects from medications can also lead to nonadherence.

OptumRx and UnitedHealthcare have been working to demonstrate how our designated specialty pharmacy programs can help engage patients to achieve higher medication adherence and reduce impact from drug and condition side effects. In addition to providing basic dispensing and counseling services, our specialty pharmacies use specialty trained nurses and pharmacists to engage and educate patients to help reduce variability in pharmaceutical care, improve medication adherence, and manage adverse effects.

We have had notable success using our specialty pharmacy program in support of patients with chronic and complex diseases such as oncology, rheumatoid arthritis, multiple sclerosis, and HIV/AIDS. We can now demonstrate similar success with renal transplants.

Our approach, which we call “total care management,” holds that it is critical to look at the patient and the condition in a holistic manner—and not just focus solely on drug management. In the case of post-renal transplantation care, anti-rejection drugs can cause unpleasant side effects such as loss of appetite, nausea or vomiting, and trembling or shaking of the hands. These side effects can be difficult for patients to manage on their own and can lead to reduced adherence to therapy and undesirable outcomes. In these cases, having the right specialty pharmacy program can make a significant difference.

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The specialty pharmacy program deploys multiple member engagement strategies designed to empower members to manage their medications and, more broadly, to take ownership of their own care. And people who are actively engaged in managing their own health have been shown to be more likely to make good health decisions: they tend to listen more closely to their physicians, monitor their health condition, and adhere more closely to their treatments.

Our engagement strategies include ongoing support such as offering patient education materials, a proactive adherence program, and interventions with members and physicians if nonadherence is detected. To date, the evidence indicates that this total care management approach can help promote improved medication adherence and lower overall health care costs. Let’s look more closely at the most recent example in postoperative renal transplantation.

METHODOLOGY

This study used established member engagement strategies with transplant recipients taking oral anti-rejection therapy. The goal was to improve both the success rates of their transplant medication therapies and the functionality of their grafts. The study compared 1 group of patients who received pharmaceutical care through the transplant specialty pharmacy program provided to the commercial customers of UnitedHealthcare through a designated specialty pharmacy. A second, similar group of patients had their pharmaceutical care provided through retail pharmacies.

The data source was the administrative claims database for approximately 14 million UnitedHealthcare enrollees. Data included prescription drug, medical, and facility claims information. We collected a de-identified pool of patients with a history of renal transplantation. Study patients were required to be continuously enrolled for at least 1 year prior to the baseline period and for 1 year afterward (follow-up period).

Once the matched retail and specialty pharmacy cohorts were identified and potential conflicts removed, 519 patients remained in each of the specialty pharmacy and retail pharmacy groups. Neither group had statistically significant differences in demographics or clinical status during the baseline period. We performed a retrospective study to compare the differences in health care costs and health services utilization between the groups.

UnitedHealthcare offers an oral immunosuppressant transplant medication specialty pharmacy program for its commercial employer group plans. We rely on claim system edits to identify the critical subset of transplant patients who need these additional services. Once the transplant patients are identified, we provide a comprehensive set of engagement strategies.

All one-on-one phone consultations are with either a pharmacist or nurse who is specially trained in transplantation. During the first consultation, we collect important background and medical information to determine each patient’s unique needs and determine how we can support them during their medicine therapy. If appropriate, follow-up consultations are scheduled where the nurse or pharmacist provides education and additional resources on specific medical conditions and how to manage symptoms; the correct way to take prescribed medicines; blood work; how to remember to take medicines; and how to manage any side effects from their medicines.

All patients receive a care plan, which is a personalized summary of key topics and self-management tips discussed during their consultation(s). Many patients also receive educational materials in the mail related to their medical condition, for example, regarding the importance of exercise and eating healthy or the possibility of financial help for these medicines (if available). A summary of the care plan is also sent to the attending physician.

OUTCOMES

The primary outcomes showed statistically significant differences between the 2 groups for mean total (overall) cost per patient as well as for mean transplant-related health care costs (the sum of pharmacy, outpatient, and inpatient) and other measures. The specialty pharmacy program is associated with lower transplant-related medical costs and lower overall health care costs, as well as higher transplant medication adherence during the first year of evaluation:

• Total health care costs during 1 year of follow-up were 13% lower in the specialty pharmacy program group.
• Transplant-related medical costs were 30% lower in the specialty pharmacy program group.
• Transplant-related office visit costs were 28% lower for the specialty pharmacy program.
• Adherence (measured via medication possession ratio) was higher (87%) in the specialty pharmacy program members than in the retail pharmacy members (83%).

These results are consistent with our research on our other specialty pharmacy programs: multiple sclerosis, HIV/AIDS, oral oncology, and rheumatoid arthritis. Studies of these patients confirm that the specialty pharmacy programs can play an important role in improving medication adherence and quality of care while reducing the overall costs of patients with complex and chronic conditions. In addition, supporting the idea that improved medication adherence is also reflected in reduced side effects and fewer doctor visits, the renal transplant study found significantly reduced transplant-related office visit costs for specialty members.

One intriguing result pertained to pharmacy costs. Anti-rejection medications are expensive. Each transplant patient faces an average medication expense of approximately $30,000 during the first year after transplantation and an additional $15,000 every year thereafter. Past experience shows that sometimes initiatives aimed at increasing medication adherence rates also show an increase in raw pharmacy costs. This increase makes sense because more people are taking their medications as part of the patient outreach programs. In any case, higher raw pharmacy costs are usually offset by lower overall medical costs.

However, in this instance we noted that despite adherence increases measured in MPR and in the number of prescriptions filled in the specialty pharmacy group, we did not see a significant corresponding increase in pharmacy costs. Rather, both overall medical costs and total pharmacy costs were lower in the specialty pharmacy group. The reason for this is the fact that UnitedHealthcare has successfully negotiated discounted transplant medication rates and services through the contracted specialty pharmacy to mitigate the effect of increased adherence contributing to higher IST medication costs.

CONCLUSION

This study demonstrates that the specialty pharmacy program works to optimize a member’s medication therapy and promote better health care outcomes through education, adherence intervention, and medication management review by specialty trained pharmacists and nurses. When aligned with our total health care approach, specialty pharmacists and nurses serve as extensions of the member’s health care team and work with the member, provider, and disease management programs to deliver holistic care management and oversight.

As our society expands coverage to new populations in the United States, our integrated delivery model uniquely positions the OptumRx/UnitedHealthcare specialty program to maximize efficiency, member experience, service, and cost. SPT

About the Author

Suzanne Tschida, PharmD, BCPS, is vice president, specialty benefit and outcomes strategy, at OptumRx, one of the nation’s leading pharmacy benefit managers and one of the Optum companies of UnitedHealth Group.