Double checking dosage led to cutting costs in half

Prime’s Insights+ flagged a claim for a possible drug dosage issue. Prime’s integrated pharmacist for the Blue Cross and Blue Shield Plan saw the medical drug claim and contacted the patient’s doctor, who then cut the prescription in half. Savings: $456,000/year.

Gut check: Something’s wrong, here.
Weight check: The script’s dosage is weight based, but there’s no weight on the chart.
Split the check: A modest change to the prescription cut the cost by half.

Gattex is prescribed to treat adults with short bowel syndrome. Short bowel syndrome is rare. Only about 15,000 to 20,000 people in the United States have it. Most often, it occurs when portions of the small intestine have been surgically removed. People who need this type of surgery may have Crohn’s disease, cancer, traumatic injuries, or blood clots in the arteries that provide blood to the intestines. Sometimes, babies are born with a short or damaged intestine.²

People with short bowel syndrome usually require special diets and nutritional supplements. They may need to get nutrition through a vein (parenteral nutrition) to prevent malnutrition.²

Gattex is a daily injection that helps improve the absorption of nutrients. It’s a peptide that helps restore the lining of the intestine.¹ Some patients who use Gattex are able to reduce their use of parenteral nutrition.²

In this case, the patient’s doctor prescribed Gattex in an amount that required two 30-vial kits being sent every month. The dosage is weight-based, yet the patient’s weight was not noted in the file.

A managed care pharmacist from Prime reached out to the doctor to discuss the dosing. Based on the patient’s weight, the doctor agreed to lower the dose of Gattex. Now the patient only gets one 30-vial kit per month. At $38,000 per kit, this resulted in savings of $456,000 per year for the plan for one member.

Insights+ can’t read doctors’ handwriting, but it can flag mismatched scripts and dosing.

Insights+ is Prime’s total drug management tool that leverages the industry-leading Artemetrx data and analytics platform. It aggregates specialty medical and pharmacy claims data and uses it to identify patterns of high-cost drug use, spend and waste in the health care delivery chain. Prime is the only pharmacy benefit manager offering insights in the form of comprehensive benefits data that can be filtered and reported in ways to suit payers’ needs.

Insights+ reduces the complexity of managing specialty pharmacy costs. This lets health plans focus more on their members.

References

1. https://www.mayoclinic.org/diseases-conditions/short-bowel-syndrome/symptoms-causes/syc-20355091
2. https://www.healio.com/news/gastroenterology/20121016/gattex_10_3928_1081_597x_20121001_16

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