In today's era of enormously expensive research and development, approval and marketing processes for drug companies, upwardly spiraling prescription prices are as certain as death and taxes, while the pressure to control expenses on the provider side is a fact of life that largely defines the reach and rationale of drug benefit plans.

Unfortunately, because of this focus on cost, today's pharmacy plans miss opportunities to promote health improvement by monitoring the compliance to prescription regimens, particularly for diseases that are high-cost to employers and life-altering for patients.

But is it possible to have it both ways - to improve employee compliance and health status while reducing employers' total health care spending through evidence-based drug therapies?

One clear solution is to encourage patients to follow the most effective pharmacy treatment plans for certain high-cost chronic conditions, such as diabetes, heart disease and hypertension.

But the key is not merely to encourage patients so much as to remove the common barriers to compliance that stand in the way of effective treatment and ultimate cost control.

A way to accomplish this goal is through a pharmacy benefit design known diagnosis-prescription pairing (Dx-Rx), which addresses some key flaws in today's pharmacy plan design and delivery systems.

Dx-Rx is unique among evidence-based designs, since it targets only combinations of diagnoses and drug therapies that have been medically proven to improve patient health, thus leading to lower overall health care costs for employers and employees.

Understanding Dx-Rx

What makes Dx-Rx different is that it drives better compliance by addressing the key barriers to optimal compliance.

It does so by reducing or eliminating patient cost-sharing for the designated diagnosis-drug pairing, so any financial barriers are eliminated or minimized.

Next, it addresses patient inertia through proactive communication to plan members whose utilization patterns may indicate reduced or minimal compliance.

Lastly, there is focused outreach to physicians in order to optimize the first-time prescribing of evidence-based Dx-Rx pairings.

This three-part approach addresses the financial, clinical and personal barriers to compliance.

Significant examples of proper Dx-Rx pairing would include the prescribing of ACE inhibitors for patients with diabetes, or recommending statins and other medications following a heart attack.

If practiced properly, the Dx-Rx approach can yield improved adherence to the drug regimens and improved outcomes for both patients and their employers.

This strategy holds particularly high potential for employers with a stable workforce and poor drug compliance rates for chronic conditions, like diabetes.

'Shades of gray'

Like any design innovation, Dx-Rx pairing is not a panacea, and shades of gray are inevitable in implementing the design.

For example, there are some drug pairings that clinicians may strongly feel will result in improved outcomes and lower cost - based on limited or anecdotal evidence - even though such a conclusion is not sufficiently supported by third-party studies and existing evidence.

Typically, such a drug would not be eligible for the preferred status of the Dx-Rx approach, but a plan sponsor could choose to include it in the preferred list for its population.

This decision would require careful consideration of clinician feedback and the limited data, which would be an unlikely level of discretionary decision-making on the part of most plan sponsors.

However, the Dx-Rx strategy at least invites pharmacy benefit plans to encourage patient compliance with prescription regimens by widening the net of eligible diagnosis-prescription pairings, which may lead to more and better data about which Dx-Rx pairings truly pay off.

Even though the Dx-Rx approach is evidence-based and represents improvement in drug plan design, a certain degree of variation will continue to exist.

Specifically, individual differences in drug efficacy still exist by patient, even for preferred pairings.

However, it's anticipated that the Dx-Rx plan structure will begin to incorporate the impact of genetic testing results once it becomes commercially viable to address these variations.

Commercial viability will vary by disease state, but it may be available within the next few years.

Even so, we needn't tie the very real potential of such an approach to eventual breakthroughs in science and their eventual application to pharmacy benefits.

Today, the reliance on traditional pharmacy benefit plan designs - built almost exclusively to reduce drug costs - tends to inadvertently discourage the pairing of diagnoses with the most effective medication simply by requiring higher copayments for many of those proven drugs.

It's well within the grasp of plan sponsors to take a proactive stance, make the most of the existing evidence and provide a financial incentive for patients to begin the most effective drug regimen, while backing up that incentive with targeted communications that can keep patients and their doctors on track when it comes to controlling disease and driving down cost.

David Dross is the national leader of Mercer's managed pharmacy consulting group in Houston, Texas.

Lisa Zeitel is a Mercer principal specializing in pharmacy benefit consulting, based in Norwalk, Conn.