In early 2017, BeneCard Prescription Benefit Facilitator made a change to its pharmacy benefit management program regarding opioid prescriptions. The company limited the starter dose of opioids that patients are allowed to receive to a five-day prescription.

The new rule was implemented based on a Centers for Disease Control and Prevention study that found the probability of long-term opioid use increases sharply after five days of opioid treatment, according to BeneCard PBF president Michael Perry.

"Since we know that the incidence of addiction goes up appreciably in that short of a time frame, we decided to limit the initial fill to five days to make sure there is a really solid clinical justification for continuing therapy beyond those five days," says Perry.

The change resulted in a more than 71% reduction in initial fill quantities, according to a study by the Vydahl Group.

The new policy rule and the results it achieved illustrate BeneCard PBF's practice of continually reviewing prescription benefit program policies to adapt them to current clinical information, according to Perry. The rule change is also characteristic of the company's value-based approach to pharmacy benefit management, which Perry claims distinguishes the company from many of its competitors.

While many pharmacy benefit managers operate on a spread model, in which their payment is the difference between the price they charge a client for pharmaceutical prescriptions and the amount they pay to the pharmacy, BeneCard PBF has a flat fee approach, Perry says. BeneCard BPF charges a set fee per insurance plan member, but its fees also includes a performance-based incentive that could result in BeneCard BPF paying a penalty to clients if it doesn't meet a pre-defined threshold for reducing pharmacy costs.

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"The pay-for-performance component is based on clinical guarantees that we have put in place right at the start of the program," says Perry. "We say we can save your plan X dollars based on our analysis, and we have a guarantee in place that we would pay a penalty if we don't achieve that clinical savings threshold."

Perry believes the flat-fee and performance incentive approaches are better aligned with clinical practices than a spread-based model because BeneCard PBF offers incentives to reduce the number of medications that patients use.

"In other financial models, the more service you provide, the more claims you pay, the more money you make," Perry notes.

In addition to its five-day opioid starter rule, BeneCard PBF's opioid policies also include a 30-day limit to the length of opioid prescriptions after the initial starter dose. The company's other policies that have contributed to controlling opioid use include prior authorization protocols and a comprehensive analytics program that flags claims at point-of-sale that are suspicious or potentially harmful to patients, according to Perry.

In a 20-month period ending in August of 2017, the monthly cost of opioid medication per covered member for one BeneCard PBF client company was reduced by 21%, according to the Vydahl report.

Twenty-nine percent of Americans take more than five medications, and many of those patients are seeing multiple doctors. Some fraud and abuse occurs because doctors don't always have a complete view of what other medications their patients are receiving, says Perry.

"What we have found is the opportunity for clinical involvement really has to do with coordination of care," Perry says. "Whether it is a fraud, waste, and abuse consideration, or it is overprescribing based on two different doctors who are not aware of the therapy that the other doctor has prescribed to the patient, in either case when we get involved those cases go through more technical edits at point-of-sale and through our analysis we are able to coordinate that care in a way that yields a higher quality of service."

The tools and techniques brought to bear in opioid medication management are essentially the same methods that the company uses to manage other pharmaceutical prescriptions as well, Perry notes.

"Approximately 30 percent of the total healthcare spend, which is now around $3 trillion, is inappropriate and dangerous care," Perry said. "We have seen that there is a lot of fertile ground to bring a more clinically-centric model to the pharmacy benefit management equation. The opioid issue is a microcosm of that, but we've seen it across the board."

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