Moving from A to Z: successful implementation of a statin switch program by a large physician group.

Abstract

To describe the implementation and impact of a centralized statin switch program at a large academic medical center.
Patients on atorvastatin were identified from electronic medical records and pharmacy claims data. Relevant information was sent to physicians for approval of the proposed switches. Approved patients were then contacted via phone and offered the opportunity to switch to simvastatin; those who switched received a new prescription for simvastatin. To assess the independent impact of the active switch process, conversion rates within a single insurance plan were compared for patients who participated in this program versus those who were contacted only by mail.
Physicians approved 3207 of the 3677 patients identified for this program. A total of 1710 approved patients accepted the switch, 704 declined, and 170 became ineligible. Information packets were mailed to 623 patients who could not be contacted. Within the single insurance plan, the generic dispensing rate for statins among the 1867 patients included in our program was significantly higher than that for the 2472 patients in the mail-only group (59.2% vs 35.8%, P <.001). Over 8 months, the direct cost of the program was $131,000 with projected annual cost savings of up to $1.14 million to payers and up to $250 for each patient who switched.
A proactive and voluntary statin switch program to promote the use of a lower cost generic alternative can be successfully implemented in a fee-for-service health system setting with benefits to patients, providers, and payers.

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© Managed Care &
Healthcare Communications, LLC
In June 2006, simvastatin (Zocor) became the third statin avail-
able as a generic, and many insurers instituted programs such as tiered
copayments and step therapy requirements to promote its use and to
encourage their members to switch from brand-name statins, if clini-
cally appropriate. For example, the University of Michigan Benefits
Office moved all brand-name statins,
except atorvastatin (Lipitor) 80 mg,
to the highest copayment level and
added a step-therapy edit requiring
patients to try a generic statin before

Full text and PDF
P
Of this amount, 22% was paid by patients out-of-pocket, 34% by pub-
lic health insurance plans, and 44% by private insurance plans. In ad-
dition, prescription drug spending is predicted to increase by 8% to 9%
annually through 2016.2,3
Targeted medication conversions to more cost-effective alternatives
represent a safe and effective way to reduce drug expenditures for pa-
tients, providers, and payers. Studies have shown that lower prescription
drug copayments are correlated with higher levels of medication com-
pliance for 3-hydroxy-3-methylglutaryl coenzyme-A reductase inhibi-
tors (statins), which are commonly used cholesterol-reducing drugs.4-7
Gibson et al studied the impact of statin copayments on patient adher-
ence and healthcare expenditures.4 They found that every $10 increase
in copayment resulted in a 1.8% reduction in medication adherence
among new users and a 3% reduction among continuing users. The study
also found that among continuing users adherent to statins, there was a
significantly lower incidence of coronary heart disease–related hospital-
ization.4 Similarly, Schultz et al found that a $15 increase in copayment
was associated with a 10% decrease in statin compliance in a retrospec-
tive analysis of claims data.6 Results from these and other pharmacoeco-
nomic studies suggest that interventions to reduce patient copayments
will improve statin adherence and, in turn, improve outcomes and re-
duce overall healthcare costs, especially in high-risk populations.7-10
All currently available statins have been shown to reduce the inci-
dence of cardiovascular events, which supports the belief that these ben-
efits are class effects.11,12 Charts comparing doses of statins that provide
similar levels of low-density lipoprotein cholesterol (LDL-C) reduction
have facilitated the substitution of one statin for another.13-15
rescription drug spending has significantly increased in the
past decade, totaling $217 billion in 2006 and representing
10.3% of total healthcare expenditures in the United States.1



In this issue

Take-Away Points / p238
www.ajmc.com
Moving From A to Z: Successful Implementation of a
Statin Switch Program by a Large Physician Group
Fangyan Z. Sy, PharmD; Hae Mi Choe, PharmD; Diane M. Kennedy, BS;
Connie J. Standiford, MD; Dawn M. Parsons, RPh, MBA; Keith D. Bruhnsen, MSW;
James G. Stevenson, PharmD; and Steven J. Bernstein, MD, MPH
Objective: To describe the implementation and
impact of a centralized statin switch program at a
large academic medical center.
Methods: Patients on atorvastatin were identified
from electronic medical records and pharmacy
claims data. Relevant information was sent to
physicians for approval of the proposed switches.
Approved patients were then contacted via
phone and offered the opportunity to switch
to simvastatin; those who switched received a
new prescription for simvastatin. To assess the
independent impact of the active switch process,
conversion rates within a single insurance plan
were compared for patients who participated in
this program versus those who were contacted
only by mail.
Results: Physicians approved 3207 of the 3677
patients identified for this program. A total of
1710 approved patients accepted the switch,
704 declined, and 170 became ineligible.
Information packets were mailed to 623 patients
who could not be contacted. Within the single
insurance plan, the generic dispensing rate for
statins among the 1867 patients included in our
program was significantly higher than that for
the 2472 patients in the mail-only group (59.2%
vs 35.8%, P <.001). Over 8 months, the direct cost
of the program was $131,000 with projected an-
nual cost savings of up to $1.14 million to payers
and up to $250 for each patient who switched.
Conclusion: A proactive and voluntary statin
switch program to promote the use of a lower
cost generic alternative can be successfully
implemented in a fee-for-service health system
setting with benefits to patients, providers,
and payers.
(Am J Manag Care. 2009;15(4):233-240)
For author information and disclosures,
see end of text.

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any other brand-name statin could be covered.16 When such
a change occurs, patients are typically notified via mail and
asked to contact their physicians to reassess therapy and ad-
just medications if necessary. When a patient calls to request
a medication change, the new prescription has to be approved
and then called in or faxed to the patient’s pharmacy. This
process involves multiple message relays that require staff and
clinician time and effort, which can disrupt clinic workflow
and may result in patients being temporarily without their
medication. All of this causes additional, avoidable costs to
patients, providers, and payers.
To assist our patients and physicians, the University of
Michigan Medical School Faculty Group Practice, which
includes approximately 1400 physicians who are directly in-
volved in patient care, initiated a voluntary program to switch
eligible ambulatory patients from A to Z (atorvastatin [Lipitor]
to simvastatin [Zocor]). Although this type of switch program
has proven effective in organizations with fixed formularies,
such as the Department of Veterans Affairs and Kaiser Perma-
nente, our program is the first we know of that targeted a large
multipayer population, including fee-for-service patients,
through a physician group.17-19
MetHoDS
This program was implemented at the University of Mich-
igan Health System (UMHS) in Ann Arbor. The UMHS is
a nonprofit teaching institution that provides more than 1.6
million outpatient visits annually between 3 hospitals and 30
health centers, which include 120 primary care or specialty
clinics. It serves a large multipayer population.
Program Development
The switch program was scheduled to begin approximately
6 months after the introduction of generic simvastatin as the
price was expected to drop at that time with multiple manu-
facturers entering the market. The program was approved by
the UMHS Ambulatory Formulary Committee and the Fac-
ulty Group Practice. The analysis of the program, reported
here, was approved by the University of Michigan Medical
School Institutional Review Board.
Patients received letters notifying them about the forth-
coming changes in prescription copayments and preferred
medications from their respective insurers. Physicians re-
ceived several e-mail messages informing them about the
changes in their patients’ prescription copayments, reasons
for the switch program, and how it would be conducted. In ad-
dition, presentations about the program were given to primary
care physicians, cardiologists, and endocrinologists at their
departmental meetings. A clinical pharmacist also visited sev-
eral high-volume clinics to answer any additional physician or
staff questions. Health center personnel were informed of the
program by their medical and administrative directors.
Patient Selection
Eligible patients were identified from electronic medical
records and pharmacy claims data provided by 2 managed care
organizations, 1 fee-for-service insurer, Michigan Medicaid,
and the University of Michigan Benefits Office. Patients were
eligible if as of January 2007, they were (1) on atorvastatin 10,
20, or 40 mg/day, (2) enrolled in a collaborating prescription
drug plan, and (3) receiving care from a UMHS primary care
physician, cardiologist, or endocrinologist.
All patients enrolled in the University of Michigan Ben-
efits Office’s prescription drug plan received identical letters
in November 2006 about the coverage changes for statins,
but only patients with a UMHS provider were included in
the active switch program. Those patients without a UMHS
provider served as the control group to help evaluate the ben-
efits of this active switch program over the passive approach
of sending patients letters.
All patients on atorvastatin 80 mg/day were excluded from
the switch program because we could not obtain similar lev-
els of LDL-C reduction with simvastatin and because there
were randomized controlled trials demonstrating benefits of
atorvastatin 80 mg/day for certain patient populations. Pa-
tients on medications with possible differential response to
simvastatin compared with atorvastatin (ie, carbamazepine,
cyclosporine, danazol, delavirdine, efavirenz, imatinib, oxcar-
bazepine, risperidone, verapamil, warfarin) were eligible for
the program, but their physicians were notified of these po-
tential drug interactions.
Program Design
An electronic database was created using Microsoft Access
2002 that included (1) pharmacy claims data from participat-
ing insurance plans; (2) patient demographics (eg, name, age,
sex, address, phone), select medication history, and latest
laboratory values (total cholesterol, high-density lipoprotein
cholesterol, LDL-C, triglycerides, alanine aminotransferase
test) from our health system’s electronic data warehouses; and
(3) the physician identified for each patient using an algo-
rithm based on the number of clinic visits the patient had in
2006. From the database, reports were produced for each phy-
sician with information on each of their eligible patients and,
for patients using a mail-order pharmacy service, a preprinted
prescription. Physicians reviewed the proposed medication
switches, changed the statin dose as needed, and approved or
declined their patients to be contacted regarding the switch
program. To facilitate this process, clinical pharmacists per-

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Successful implementation of a Statin Switch Program
the switch program. Personnel included an internist, a clini-
cal pharmacist, a data analyst, a programmer, an administra-
tor, an administrative assistant, and 9 pharmacy and nursing
students. The amount of time each individual spent on the
program was determined to calculate the number of full-time
equivalent staff needed for this program.
Total program savings were calculated from an insurer’s
perspective and were based on the differences in estimated
drug costs for atorvastatin and simvastatin for the patients
who switched as part of this program. For a 30-day supply of
atorvastatin 20 mg, we used the average wholesale price mi-
nus 10%, which was $110 in September 2007.21 For a 30-day
supply of simvastatin 40 mg, we used the maximum allowable
cost in Michigan, which was $10 in September 2007.22
Statistical Analysis
Descriptive statistics were utilized for the demographic
data. The chi-square statistical test was utilized for compara-
tive analyses and a P value of <.05 was considered to be sig-
nificant. All analyses were performed with STATA version
8.1 (StataCorp, College Station, TX).
ReSultS
In January 2007, 3677 patients met all the inclusion
criteria. Baseline characteristics were similar for patients
who did and did not switch from atorvastatin to simvas-
tatin (Table 1). These patients were assigned to 182 physi-
cians, 154 (84.6%) of whom responded with their decisions
on 3336 (90.7%) patients (Figure 1). Of the nonresponding
physicians, 24 (13.2%) were specialists (cardiologists or endo-
crinologists), accounting for 114 (3.1%) patients. Physicians
approved the proposed switches for 3207 (87.2%) patients;
of these patients, 1710 (53.3%) agreed to switch from ator-
vastatin to simvastatin. A total of 52 (1.4%) patients who
initially declined the switch and 37 (1.0%) patients unreach-
able by phone were subsequently switched by their physicians
during clinic visits.
Patients on lower doses of atorvastatin were more likely
to switch to simvastatin (P <.01). The average atorvastatin
dose of patients who agreed to the switch was slightly lower
than that of patients who did not switch (19.0 mg vs 20.4 mg,
P <.01). Almost all the switched patients (99.4%) were con-
verted from atorvastatin to an equipotent or greater dose of
simvastatin. Only 59 (3.5%) patients who switched were on
1 or more drugs considered to interact specifically with sim-
vastatin; 39 (2.3%) of those patients were on warfarin. These
patients were flagged and additional counseling regarding the
potential effects of simvastatin on their anticoagulation tests
were provided by a clinical pharmacist.
formed a preliminary review of the reports for 7 high-volume
physicians (ie, more than 50 assigned patients, range 55-130),
as well as several others who asked for help. A total of 972
(26%) patients were reviewed by 3 clinical pharmacists. Phy-
sicians returned their reports to the switch team and the in-
formation was entered into the program’s database.
It was recommended that patients switch to an equipotent
or greater dose of simvastatin, with respect to LDL-C reduc-
tion: (1) from atorvastatin 10 or 20 mg to simvastatin 40 mg,
based on the published results supporting moderate dosing
of statins,20 and (2) from atorvastatin 40 mg to simvastatin
80 mg.
A computer-aided telephone interview program was de-
veloped to guide pharmacy students in their discussions with
eligible patients. Using a standardized script, the students
informed patients about the program, told them that their
physicians had approved the switch, and asked whether pa-
tients wanted to switch from atorvastatin to simvastatin. A
maximum of 6 attempts were made to contact each patient,
including 2 during weekdays, 2 during weeknights, and 2 on
Saturdays. An information packet about the program was
mailed to patients who could not be contacted.
Patients who elected to switch received a new prescrip-
tion for simvastatin, which was either called in to their local
pharmacy within 24 hours or sent to them if they used a mail-
order pharmacy. Patients using mail-order pharmacies had the
option of having a 30-day supply of simvastatin called in to
a local pharmacy if they had fewer than 28 days of atorvasta-
tin remaining. Each patient also received a letter confirming
the medication change and a laboratory requisition form for a
fasting lipid profile and serum alanine aminotransferase test,
to be drawn approximately 8 weeks after initiating simvasta-
tin. The patients’ electronic medical records were updated.
At the program’s conclusion, physicians were given a report
summarizing their patients’ switch status.
Effectiveness of Switch Program
We took advantage of a natural experiment and com-
pared the proportion of patients in 1 prescription drug plan
who converted from atorvastatin to simvastatin in the active
switch program with a similar group of patients in a passive
switch program (ie, they received a letter notifying them of
the copayment increase for brand-name statins). As in the
active switch program, patients in the passive switch program
who either were on a brand-name statin other than atorvasta-
tin or were on atorvastatin 80 mg/day were excluded.
Cost Analysis
Total program expenditures include materials/supplies and
the salary and benefits of personnel directly involved with

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Active Versus Passive Switch
The University of Michigan Benefits Office had the most
patients in this study, with a total of 4339 patients on atorva-
statin 10, 20, or 40 mg/day. These patients all received a let-
ter notifying them of the copayment increase for brand-name
statins. Those University of Michigan employees or their
dependents who had an UMHS provider were included in
the active switch program (n = 1867) and the passive switch
group consisted of the remaining 2472 patients who had a
non-UMHS provider.
As shown in Table 2, patients in the active group were
younger (58.1 vs 61.1 years old, P <.001) and were less likely
to have drug interaction(s) with simvastatin (5.4% vs 8.3%, P
<.001). By the third quarter of 2007, generic simvastatin was
being used by 59.2% of patients in the active switch program
compared with 35.8% of patients in the passive switch group
(P <.001; Figure 2). The 23.4% greater generic statin dis-
pensing rate among switch program participants resulted in a
$150,000 cost savings by the end of the third quarter of 2007
and an estimated $370,000 in cost savings annually, based on
the University of Michigan Benefits Office’s prescription drug
plan cost structure. Patients saved up to $168 annually due to
lower copayment amounts ($7 for simvastatin vs $24 for ator-
vastatin), excluding any unmeasured indirect costs (eg, time
spent to contact a physician regarding this switch program).
The total program cost was approximately $131,000, in-
cluding $7500 for materials/supplies and $123,500 for the 1.9
full-time equivalents who worked on the program from No-
vember 2006 through June 2007. This total does not include
the time that physicians and 2 ambulatory care clinical phar-
macists spent reviewing patients for this program, although
others might wish to include the opportunity costs of this time
in such a calculation. This program was funded by the Uni-
versity of Michigan Medical School Faculty Group Practice,
which received a nominal monetary amount for each patient
converted from atorvastatin to simvastatin from 2 of the in-
surers to help cover the expenses of providing this service to
our patients.
Total projected annual cost savings ranged from $150
to $250 for each patient because of lower copayments and
n Table 1. Baseline Characteristics of Patients Eligible for the Statin Switch Programa
CharacteristicSwitched (n = 1710) Not Switched (n = 1967) P
Mean age, y (± SD)
58.6 (11.0)57 .7 (11.1) .700
Female
714 (41.8)812 (41.3) .771
Indication
.628
Primary prevention 1153 (67 .4) 1341 (68.2)—
Secondary prevention557 (32.6) 626 (31.8)—
Atorvastatin dose
<.001
10 mg739 (43.2) 796 (40.5)—
20 mg688 (40.2) 731 (37 .2)—
40 mg 283 (16.5)440 (22.4)—
Potential drug interaction(s) with simvastatinb
59 (3.5)129 (6.6) <.001
Prescription drug plan
<.001
university of Michigan Benefits office 938 (54.9) 929 (47 .2)—
Blue Cross Blue Shield of Michigan 59 (3.5)67 (3.4)—
Blue Care Network 185 (10.8)174 (8.8)—
M-CARe 492 (28.8)678 (34.5)—
M-CAID (managed Medicaid) 36 (2.1)119 (6.0)—
Prescriberc
<.001
Specialist45 (2.6)165 (8.4)—
Primary care provider1665 (97 .4) 1802 (91.6)—
aValues are number (percentage) unless otherwise indicated.
bonly drug interactions specific to simvastatin were flagged (carbamazepine, cyclosporine, danazol, delavirdine, efavirenz, imatinib, oxcarbazepine,
risperidone, verapamil, and warfarin).
cSpecialist group included cardiologists and endocrinologists; primary care provider group included general medicine, family medicine, and geriatric
medicine.

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Successful implementation of a Statin Switch Program
from $670,000 to $1.14 million for the pay-
ers because of lower drug costs. The range in
cost savings for the payers reflects the savings
that might accrue if all payers engaged in a
passive approach such as that by the Univer-
sity of Michigan Benefits Office or if none did.
Allowing for some variation in drug pricing
and assuming that patients get monthly refills,
the cost difference between atorvastatin and
simvastatin translates to an annual savings
of about $1000 per person switched for the
payer.
DISCuSSIoN
Our results demonstrate that physicians in
a large academic medical center that serves
a diverse patient population can successfully
conduct a centralized statin switch program.
In contrast to some of the other medication
switch programs reported, the voluntary and
flexible nature of our program allowed physi-
cians and patients to be in control of the switch
process, from approval to dosing to prescription
processing.17,19,23-25
Our security-enabled computer-aided tele-
phone interview program facilitated the
electronic management of our database and
allowed us to track the status of our patients
from initial data load through every step of
the switch process. Dynamic call and print
queues were set up based on prespecified algo-
rithms and were automatically updated in real
time. Multiple queries and reports were built in
n Figure 1. Patient Status Flow Chart
n Table 2. Baseline Characteristics of Patients Enrolled in the University of Michigan Benefits Office’s Prescription
Drug Plan by Type of Switch Programa

Characteristic
Active Switch Program
(n = 1867)
Passive Switch Program
(n = 2472)

P
Mean age, y (± SD)
Female
Atorvastatin dose
10 mg
20 mg
40 mg
Potential drug interaction(s) with simvastatinb
58.1 (11.1)
821 (44.0)
61.1 (12.9)
1119 (45.3)
<.001
.396
.029
811 (43.4)
674 (36.1)
382 (20.5)
100 (5.4)
1024 (41.4)
988 (40.0)
460 (18.6)
205 (8.3)<.001
aValues are number (percentage) unless otherwise indicated.
bonly drug interactions specific to simvastatin were flagged (carbamazepine, cyclosporine, danazol, delavirdine, efavirenz, imatinib, oxcarbazepine,
risperidone, verapamil, and warfarin).
3677 eligible patients
Approved by physician
n = 3207 (87.2%)
Physician rejected switch
n = 129 (3.5%)
Physician did not respond
n = 341 (9.3%)
Patient declined switch
n = 704 (22%)
Patient no longer eligiblea
n = 170 (5.3%)
Unable to contact patientb
n = 431 (13.4%)
Other
n = 192 (6.0%)
Patient accepted switch
n = 1710 (53.3%)
aIneligible patients were those who were no longer taking atorvastatin, whose ator-
vastatin dose had been increased to 80 mg/day, who were no longer being followed
at the university of Michigan Health System, or who were deceased.
bPatients who could not be contacted were those who neither responded to 6 phone
call attempts nor to mailed information.