Substantial savings are inherent in just changing to an a priori online system. The field developed strategies coming from field experienced administrators are the really big savings' tools. The TeleCLAIM++ system is an accumulation of a variety of different strategies that uniquely control costs in various circumstances that are determined by the administrators. The strength of the DpRx system is the empirically-tested variety of options made available to the administrator.

BIG SAVINGS DELIVERED BY THE PBM SYSTEM

The TeleCLAIM PBM system is a software package that has evolved over 18 years of DpRx's Pharmacy Benefit Management experience. For this reason DpRx can provide creditable assurance that the system’s capabilities and flexibility will accommodate all anticipated government needs today and in the foreseeable future.

Justification for implementation of the PBM software is explained as follows:

Sources of Drug Benefit Savings

Cost Containment measures can provide potentially ever-escalating savings in the following areas:

·        Curtailment of Abuse and Over-utilization by limiting Rx’s days supply, single Rx amount, maximum quantity without manual over-ride.

·        Elimination of well-honed and widely-used fraudulent schemes by perpetrators.

·        Limiting disease-specific patients to only disease-appropriate drugs.

·        Limiting Specialists to prescribing only drugs used in their Specialty practice area.

·        Limiting certain drugs to only the corresponding Specialists.

·        Substitution of therapeutically-equivalent cheaper (Generic) drugs.

·        Optional use of Deductibles and/or Maximum benefit amounts to limit an unrestricted runaway cost. Maximum quantity also available.

·        Using token and/or targeted Co-Payments (recipient share of cost) in the future if deemed necessary for excessive utilization or at any time for drugs not covered in formulary and issued a Prior Authorization override.

These cost containment initiatives, and many others, are available with the TeleCLAIM Internet program. Based on the history of drug benefit programs not managed by PBM on-line, real-time systems, the industry concluded that costs can potentially exceed the optimum expenditures by up to 25%.

The PBM system is prepared to implement a Co-payment feature when it is deemed necessary by the administration without any special modifications to the system. (Drug benefit programs that are without Co-Payment deterrents are most susceptible to over-utilization and this alone can account for cost reductions in excess of 10%. Other cost inflation aspects can add another 15% of waste.)

Cost of Waste Due to Fraud and Abuse

There are many schemes that are used to gain fraudulent income by manipulating a drug benefit program that is vulnerable due to the inadequacies of retrospective basic controls or lack thereof. This has been particularly true in countries that provided drugs to its citizens without any token payment (“co-payments”). Such countries subsequently changed their programs to require a small token payment to eliminate the totally free inducement for unnecessary consumption.

Trinidad’s Chronic Disease program serves nearly 300,000 citizens. At an average cost of an estimated TT$150 per Rx (90 day supply), the minimum monthly national cost approximates TT$30 million dollars or TT$360 million annually (this estimate may be on the low side as the benefit program matures).

With a 10% expansion due to Fraud alone this amounts to TT$3 million per month or TT$36 million wasted annually.

An investment of less than 2% of costs for PBM controls can virtually eliminate this waste and save a net TT$24 million annually – also a conservative estimate.

This waste does not include Abuse or Over-utilization which is shown around the world to be at between 5% and 10% adding to the Fraud waste. It is reasonable to assume that this waste is at least 5% or another TT$18 million annually.

The aggregate of waste is TT$54 million annually or $TT36 per capita.

How Cost-Containment PBM Features Minimize Waste

 There exists a multitude of techniques that reduce and eliminate Fraud and Abuse. The most effective of these measures are the following:

·        Limiting dispensing Rxs to Disease-specific drugs;

·        Limiting of refills of the same Rx to the Days Supply – called “refill-too-soon” intercepts;

·        Intercepting duplicate Rx dispensing by recipients simultaneously using multiple pharmacies during the first days-supply period;

·        Advance confirmation of eligibility of the recipient;

·        Prevention of duplicate therapy – intercepting concurrent dispensing of same class of drug;

·        Gender intercepts for drugs meant to be used exclusively by one gender;

·        Preventing excessive Dosages prescribed without using smaller amounts recommended by manufacturer due to age and/or sex;

·        Limiting Specialists to drugs appropriate only to their specialty

DpRx’s solution will be free of risky trial and error development for the implementation of its PBM system. The system is designed to provide proven latest-techniques of Cost Containment emulating the world’s most advanced pharmaceutical methodology. It is not an eRetail system that simply processes purchases without regard to the benefit sponsor costs and patient efficacy. This is the primary characteristic that elevates its value above other competitive “PBM” products.

Pre-Online/computer Drug Benefit programs historically were rife with fraud and abuse. The results were runaway expenditures and minimal therapeutic benefits for the pharmaceutical’s prescribed. 

It should be noted; however, the with the advent of PBM control effectiveness there exists no intention to simply reduce or curtail appropriate therapies since drug therapy is the most cost-effective means of treating disease.

Most physicians and healthcare specialists acknowledge that the appropriate application of pharmaceutical therapies can greatly reduce hospital admissions due to complications of disease.

Hospital admissions and their attendant costs are ordinarily at least 40% of total healthcare budget  costs. Compared to the approximate 12% cost of pharmaceuticals in the same healthcare budget, curtailment of appropriate drugs and inattention to therapy compliance strategies is a modus operandi to avoid.

Adopting policies that support the leveraged advantage of maximizing the application of drugs, where medically indicated, is a strategy that all healthcare professionals consider indisputable.

DpRx proposes to install its Internet PBM system for the Trinidad/Tobago government’s drug benefit citizen programs. This document is designed to address the manner and means of that implementation with the most expeditious planning.

An alternate approach of availing the PBM solution for the CDAP program is to have the Pharmacy community  implement a PBM as an added feature of their dispensing services.

It would be a simple analysis and task to illustrate, with a small increase in dispensing fee by the stores to the government for the PBM service, that the fee delta increment would be a very small offset to the much greater savings provided by reduced utilization and all the other cost containment measures applied. 

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