Effect of Health Plan and Physician Clinic Collaboration on Increasing Omeprazole Use

Proton pump inhibitors (PPIs) represent a costly therapeutic drug class for most health plans. PPIs are potent inhibitors of gastric acid secretion. Marketed PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (AcipHex), esomeprazole (Nexium), and pantoprazole (Protonix), of which only omeprazole and pantoprazole are currently available generically. These medications are used to treat persons with acid- related disorders, including peptic ulcer disease, gastroesophageal reflux disease, and Zollinger-Ellison syndrome; to treat and prevent gastroduodenal ulcers associated with the use of NSAIDs; and as part of a treatment regimen for the eradication of Helicobacter pylori.

The available PPIs are similar in chemical structure, mechanism of action, and effectiveness. Although some differences in effectiveness of PPIs have been reported, the magnitude of the differences has been small, with uncertain clinical importance.^1-3 At the same time, the acquisition price of omeprazole has dropped to a point at which many health plans are implementing programs to encourage providers and members to favor the use of omeprazole over other PPIs. While the health plan evaluated strategies to increase its physicians’ generic prescribing ratio, the class of PPIs presented an opportunity to promote therapeutic substitution from brand-name PPIs to generically available omeprazole while maintaining similar clinical effectiveness.

Effective July 2007, SelectHealth requires step therapy using omeprazole before the plan will cover a different PPI. The other covered PPI options during the study period were lansoprazole and rabeprazole at a tier 2 (preferred brand) co-pay/coinsurance level. Esomeprazole was in tier 3 (nonpreferred brand) and was covered only if the patient’s condition did not improve following trials of omeprazole, lansoprazole, and rabeprazole. Pantoprazole became available as a generic during the study period; it was covered at tier 1 and also required step therapy. Switching to omeprazole is also encouraged through SelectHealth’s GenericSample program, under which members can try certain generic prescription drugs at no cost (on a one-time basis per medication) through participating retail pharmacies.

One difficulty for physicians is the identification of patients for whom therapeutic substitution that favors a generic may be applicable. With a recently instituted step-therapy requirement to try omeprazole first, patients naive to PPI therapy could receive a prescription for a brand-name PPI and take it to the pharmacy only to find out that it is not covered without a prior trial of omeprazole. However, patients who had previously filled a prescription for a brand-name PPI would be allowed to use up their remaining brand-name PPI refills. Another barrier is the difficulty in offering a therapeutic alternative to patients outside their routine office visits.

When the health plan, in collaboration with clinical management and physicians, launched a pilot program with 1 outpatient clinic, the share of omeprazole among all PPIs prescribed at this clinic was low compared with the health plan’s overall utilization of omeprazole. The health plan supplied the clinic with past PPI utilization data, and the clinic mailed out prescriptions for omeprazole. After evaluating the effects of collaboration with the pilot clinic, the program was then expanded to 4 other pilot clinics.

Methodology
In 2007, SelectHealth sought to increase the use of generically available omeprazole relative to other brand-name PPIs to reduce costs. This study evaluates changes in omeprazole utilization as a result of targeted efforts to encourage physicians to consider prescribing omeprazole in place of brand-name PPIs. One clinic (clinic A) was chosen as an initial pilot site for the intervention. The intervention was designed by the health plan in collaboration with a clinic manager and discussed with the medical director and lead physician at the clinic site. Utilization data were gathered for the 3-month period, or quarter, before the intervention, the quarter during the intervention, and the quarter following the intervention.

The study’s second phase measured omeprazole utilization at 4 additional clinics. For an overview of the methodology used, see Study Time Line. The study design was approved by the Intermountain Healthcare Office of Research and Institutional Review Board.

The health plan’s paid prescription claims were used to identify members who filled prescriptions for brand-name PPIs written by physicians at clinic A. Specifically, 245 members were identified who received a prescription for a brand-name PPI between April 1 and September 30, 2007. Member information was given to the clinic and subsequently evaluated by the physician who determined whether a new prescription for omeprazole would be appropriate in place of a brand-name PPI. The clinic created a letter in which the member’s physician described the opportunity for generic drug savings, and explained that all PPIs have a similar mechanism of action and clinical efficacy. Along with the letter, each targeted member received a prescription for omeprazole with 6 refills. The letters were sent in October 2007. Members could then decide whether they wanted to try omeprazole or continue their current therapy.

Prescription claims were analyzed 5 months after the letters were sent in order to capture data from the quarter before the intervention (2007Q3), the quarter during the intervention (2007Q4), and the quarter following the intervention (2008Q1). Claims were analyzed by the number of omeprazole prescriptions, PPI prescriptions, members taking omeprazole, and members taking any PPI. The market share of omeprazole prescriptions at clinic A was then compared with the health plan’s overall market share of omeprazole prescriptions, which was used as a benchmark. The health plan’s overall prescription share was calculated by dividing the number of the plan’s paid omeprazole claims by the number of all PPI paid claims.

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