Executive Briefing | by Athena Mandros | June 1, 2017
Pharmacy lock-ins are not new – the program has been around since at least the 1970s, but recently it has gained attention as one tool to fight the current abuse and misuse of opioids. Although primarily used in Medicaid, pharmacy lock-in programs have recently expanded to include other payers. The Comprehensive Addiction and Recovery Act of 2016 (CARA) allows Medicare Part D and Medicare Advantage plans to operate a pharmacy lock-in program (see Summary Of The House–Senate Conference Report On S. 524, The Comprehensive Addiction And Recovery Act). And Anthem announced in 2016 that all affiliated health plans would operate a pharmacy lock-in program regardless of coverage type (see Pharmacy Programs That Tackle Inappropriate Opioid and Rx Drug Use Can Improve Drug Safety and Health Care Quality).
First, for a definition – pharmacy lock-in programs (also known as coordinated services programs or beneficiary restriction programs) are programs used primarily to restrict overutilization of medications. Specifically, programs may require beneficiaries to receive all prescriptions through one pharmacy, have all prescriptions written by one prescriber, receive health care services from one clinical professional, or all three depending on how the program is designed. While criteria vary by state, common criteria for enrollment include filling prescriptions at four or more pharmacies in a certain time period or receiving 10 to 15 prescriptions over a certain time period. Once identified, consumers are locked-in to either one pharmacy, one prescriber, or both depending on the state. The idea that is by limiting the consumer to one pharmacy/and or prescriber they are less likely to over utilize or misuse medications and/or services.
Like most Medicaid policies, the number of consumers in pharmacy lock-in programs is highly variable by state. There are only two state Medicaid FFS programs without a lock-in program. However, in 2015, eight states reported that none of their Medicaid beneficiaries were enrolled in their pharmacy lock-in program (see Medicaid Drug Utilization Review State Comparison/Summary Report FFY 2015 Annual Report: Prescription Drug Fee-For-Service Programs). A review of the 38 states with managed care programs, 27 either require or give the health plan the option to implement a pharmacy lock-in program. For the specifics about each state Medicaid plan, check out our new report, Use Of Pharmacy Lock-In Programs By State Medicaid Programs: An OPEN MINDS Reference Guide.
The “success” of lock-in programs is up for debate. State evaluations of the programs suggest lower levels of utilization and reduced costs for consumers enrolled in the program. For example Washington State found a 37% decrease in physician visits, 33% decrease in emergency department visits, and 24% decrease in the number of prescriptions. In 2015, of the 23 states that reported cost savings, the majority (18) reported savings under $500,000 – but Pennsylvania and New York reported savings of $53.6 million and $114 million in Medicaid costs, respectively (see Medicaid Drug Utilization Review State Comparison/Summary Report FFY 2015 Annual Report: Prescription Drug Fee-For-Service Programs).
There are no broad studies of the effects on consumers. A study of North Carolina Medicaid beneficiaries found that while Medicaid prescriptions for controlled substances decreased by 17% after enrollment in the lock-in program, beneficiaries were 3.6 times as likely to purchase prescriptions for controlled substances out-of-pocket see Controlled Substance Lock-In Programs: Examining An Unintended Consequence Of A Prescription Drug Abuse Policy).
The mixed view of pharmacy lock-in programs is reflected in the opinions of my colleagues. For example, my colleague Robert Dunbar commented on the potential to identify prescription drug abuse, with a caveat:
There is a scarcity of substance abuse assessment, education, and treatment services. Historically little attention has been given at the national and state levels to development and implementation of comprehensive substance abuse identification and treatment plans. Because of the opioid epidemic, national and state governments are recognizing the need to plan and take action necessary to address this public health crisis. Medicaid pharmacy lock-in programs have the potential to contribute to a reduction in opioid abuse, deaths, and related health care costs. Pharmacy lock-in programs can identify people who are in need of assessment for opioid addiction and facilitate referral to medically necessary treatment resources. However, Medicaid lock-in programs must give much greater priority to increase access to necessary services and perhaps less priority to simple cost savings. Medicaid lock-in programs must be a component of a comprehensive opioid abuse plan that addresses identification, assessment, and access to treatment resources, as well as cost containment.
OPEN MINDS Senior Associate Sharon Hicks echoed that point:
The opioid epidemic in this country is at a massive scale, so any programs that help identify persons with service needs, with the intention of getting them to services, are helpful. The difficulty with many of these types of pharmacy related programs is that they are less concerned with service access and more concerned with dollar savings. For example, the Pennsylvania program imposes a limit of six medications with requirements for clinicians to contact managed care companies to ask for waivers. The additional administrative burden on the clinicians notwithstanding, when a person needs medications for diabetes, heart disease, and schizophrenia, any program that limits access to those medications can significantly compromise that person’s health status. No one should have to choose which of their diseases is the most important to treat. Cost savings programs are important and can be done in a way that is both humane and clinically appropriate. Arbitrary drug limits is not in that category. In summary, programs that save money and help assure that consumers get access to treatment are to be applauded and copied, while programs that only limit treatment will likely end up, in the long run, costing much more than they save.
While it appears that more pharmacy lock-in programs are on the horizon, the question of how they fit in the myriad of integrated care coordination initiatives remains. For a current snapshot of state Medicaid plan policy on pharmacy lock-in programs, check out Use Of Pharmacy Lock-In Programs By State Medicaid Programs: An OPEN MINDS Reference Guide. The report includes background information on pharmacy lock-in programs, detailed information on lock-in design in selected states, a state-by-state list of whether the FFS or managed care program has a lock-in program, and a discussion of the results and literature surrounding the programs.
For more, join us next week in New Orleans at The 2017 OPEN MINDS Strategy and Innovation Institute for the session “The Shift From Residential: The Changing Addiction Treatment Landscape” led by Jim Gargiulo, OPEN MINDS, Senior Associate, and featuring Robert J. Budsock, MS, LCADC, President & CEO, Integrity House; Maks Danilin, Strategic Account Executive, Aware Recovery Care, Inc.; Amy Gallagher, Psy.D., Vice President, Whole Health, LLC, a subsidiary of Mind Springs Health, Inc.; and Anthony J. Mele, Psy.D., Chief Clinical Officer, Sovereign Health. Can’t attend? Follow our coverage on Twitter @openmindscircle – #OMInnovation.