THE OPPORTUNITY When you manage drugs better, you manage the whole healthcare system better Facts:Perspectives • ForWiring prescription drugs, healthcare is wired Healthcare: A Linchpin totoday. Reform • P eople with chronic and complex diseases account for 96 percent of drug costs and 75 percent of medical expenses in the United States. • F or 88 percent of chronic and complex diseases, drugs are a first line of medical intervention.
David of B. aSnow, • I nstability patientJr., with a chronic or complex condition is most often Chairman and Chief Executive Officer tiedMedco to deviations from accepted clinical protocol or noncompliance. • D eviations from protocol and noncompliance cost the system billions of dollars annually.
THE OPPORTUNITY When you manage drugs better, you manage the whole healthcare system better
Facts:
David B. Snow, Jr., Chairman and Chief Executive Officer, Medco, is a healthcare industry veteran and innovator who has created and implemented solutions to manage the rising costs of healthcare for more than 30 years.
• For prescription drugs, healthcare is wired today. The following material is based on a presentation delivered by Mr. Snow • P eople with chronic and diseases account for 96 percent drug to complex the American Enterprise Institute in Marchof2009. costs and 75 percent of medical expenses in the United States.
David B. Snow, Jr., • Officer For 88 percent of chronic and complex diseases, drugs are a first line of Chairman and Chief Executive medical intervention. Medco
• I nstability of a patient with a chronic or complex condition is most often tied to deviations from accepted clinical protocol or noncompliance. • D eviations from protocol and noncompliance cost the system billions of dollars annually.
I believe that wiring healthcare, what many refer to as “Health IT,” will enable a sweeping transformation — a change every bit as profound as replacing a candle with an electric lightbulb — and, in similar fashion, holds the promise of moving healthcare out of the Dark Ages. The power of Health IT is unleashed by connectivity.
That’s a bold statement and it’s clear that not everybody is a believer. In fact, my own father — a physician now enjoying his retirement — recently e-mailed me to argue that electronic medical records are a complete waste of money. Consider the irony: a retired doc e-mailing his son — a CEO of a leading healthcare organization — on how Health IT (information technology) is a waste of money. My father’s view of Health IT is confined to the idea of digitizing all those ragged paper files that clog the aisles and back rooms in the doctor’s office. To that extent, he’s absolutely right. If the information simply moves from paper to digital and remains locked away in the doctor’s office, we’re only freeing up a little floor space, and saving a few trees — and that won’t do much to improve healthcare. The power of Health IT is unleashed by connectivity. Think of how ATMs transformed banking. A truly wired system will dramatically improve quality and efficiency, and provide transparency and accountability. It’s the pathway to what we at Medco call “making medicine smarter.”
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There are three rules that I apply to any type of reform, these are especially appropriate guideposts for Health IT reform. 1. K eep it simple. If you make reform complicated and people don’t understand it, they will reject it out of hand.
Government creates guardrails on the highway, within which the private sector can perform.
2. Change must be evolutionary, not revolutionary. We should not pursue “Big Bang” Health IT reform for two reasons: First, too much change too quickly— particularly in a politically charged environment—guarantees opposition from all quarters, resulting in gridlock. Equally important, meaningful reform requires that we take a long-term view, building on incremental steps toward a shared long-range objective. 3. M eaningful Health IT reform requires government and the private sector to work together and honors their respective roles. Government creates guardrails on the highway (such as operability standards), within which the private sector can perform. Government must promulgate and regulate. And when government does that well, it’s amazing how the private sector is stimulated to operate and innovate as it races to create value.
Purging waste from the system
The care of patients with chronic and complex conditions accounts for 96 percent of the nations’ drug spending, and 75 percent of medical spending.
Wiring healthcare creates a foundational opportunity to attack the real waste in our healthcare system. What waste? We can quibble over the exact number, but knowledgeable people agree it’s a huge opportunity—as much as half of the $2.3 trillion we expect to spend in 2009 on healthcare in the United States. One significant area of waste relates to how we manage chronic and complex conditions. That’s important because the care of patients with chronic and complex conditions, about half of the U.S. population, accounts for 96 percent of the nation’s overall drug spending and 75 percent of medical spending. If you review the list of chronic and complex diseases, in 88 percent of the cases, prescription drugs are a first line of defense for treatment. Part of the waste in the healthcare system is due to drastic variances in practice around the same disease for the same type of patient, tied to the age of the physician, their training, and even their geographic location. For example: • F amily physicians and pediatricians treating asthma report following National Heart, Lung, and Blood Institute guidelines for using inhaled steroids less than 55 percent of the time.1 • P atients with heart disease and high cholesterol who live outside the northeast are 17 percent less likely to be on statins, a treatment that lowers cholesterol and saves lives.2
Sources: 1. Cabana MD, Abu-Isa H, Thyne SM, Yawn B. Specialty differences in prescribing inhaled corticosteroids for children. Clinical Pediatrics. 2007 Oct; 46 (8):698-705. Epub 2007 May 14. 2. Condliffe S, Link C. Variations in the Prescribing Patterns of Statins for Persons Diagnosed with Dyslipidemia and CHD. Paper presented at the annual meeting of the Economics of Population Health: Inaugural Conference of the American Society of Health Economists, Madison, WI, June 4, 2006.
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• T he likelihood of patients with lower back pain receiving powerful narcotics ranges from 5.7 percent in Massachusetts to 52.9 percent in South Carolina.3 There’s no viable justification for this broad disparity in treatment and outcomes. These aren’t narrow, slight bell curves—the variances are both wide and steep.
The efficiencies from wiring healthcare will save an estimated $680 billion a year.
So how can doctors provide more consistent treatment that benefits patients and helps to reduce costs? I support an evidence-based, protocol-driven approach to medicine, which would ensure that all patients benefit from the best practices and latest science. Tailoring practice to protocol in both an inpatient and outpatient environment creates a mechanism for feedback on performance that improves the way we take care of patients over time and uses healthcare dollars more wisely.
Technology transforms The efficiencies from wiring healthcare will provide improved chronic and complex patient care, address systemic cost and care issues related to the looming financial strain in Medicare, reduce the need for physicians to practice defensive medicine, and set the stage for tort reform—yielding a combined savings opportunity estimated at $680 billion a year. There’s another $320 billion in waste associated with wellness and prevention, which is not directly dependent on wired healthcare. When you add it up, eliminating these various types of waste in the system represents a $1 trillion opportunity. Source: 3. Webster BS, Cifuentes M, Verma S, Pransky G. Geographic variation in opioid prescribing for acute, work-related, low back pain and associated factors: a multilevel analysis. American Journal of Industrial Medicine. 2009 Feb; 52 (2):162-171.
Wiring healthcare could save billions annually The efficiencies from wiring healthcare will provide improved chronic and complex patient care, address systemic cost and care issues related to Medicare, reduce the need for physicians to practice defensive medicine, and set the stage for tort reform. The combined savings is estimated at $680 billion a year.
$200
$680
Tort reform3
Total
($ billions)
$130 $350
Eliminate waste associated with care for chronic / complex patients1
Medicare solutions2
Sources: 1. RAND Corporation Study, 2005; Institute for Health and Productivity Management; Medical Care. 2004 Mar; 42(3); 200-209. 2. CMS Office of the Actuary; Department of Health and Human Services. 3. CMS National Health Accounts, 2005; Midwest Business Group on Health, April 2003.
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Wiring healthcare enables the system to focus on continuous treatment of chronic disease.
So, why do I see the potential of wired healthcare so differently than my physician/ father? Simply converting records from paper to digital in a doctor’s office barely scratches the surface. Wired healthcare creates a central repository that enables a 360-degree patient-centric view of every aspect of care. It’s the data and results from the lab, from the health plan, from the pharmacy, from the hospital, and from the doctor or doctors—all organized around the patient, so we know what the patient is doing or not doing. This allows healthcare management organizations to: • Monitor medication compliance • Ensure a patient’s treatment conforms to nationally accepted protocols of care • Help the patient save money by using generic medications I refer to the above three situations collectively as “gaps in care” that can result in higher costs and suboptimal clinical outcomes. Wiring the healthcare system would help organizations detect and close those gaps in care. Wiring healthcare creates the infrastructure to convert the system from a focus on episodic acute treatment to continuous treatment of chronic disease. This transforms the care delivered and provides real-time feedback into what works and what doesn’t work.
Raise the standard of care with patient-centric electronic health records Hospitals Laboratories
Physicians offices
Payors
Electronic health records (EHR) u u u u
Ambulatory centers
Wired healthcare creates a central repository that enables a 360-degree patient-centric view of every aspect of care.
PBMs
Trusted repository Open standards Secure access Privacy
Pharmacies
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My confidence in wired healthcare isn’t blind faith. It’s based on the history of pharmacy practice in America, which provides proof of the power of collaboration between government and the private sector.
We should build on
Take one example: In 1990, a federal law was enacted to wire pharmacies from end to end, nationwide. Medco has built on that wired foundation and today we can identify and close clinical and treatment gaps in care.
prescription drug care
So as we debate healthcare reform in the United States, we should build on the foundation that prescription drug care is already wired today. Integrated data added to a wired environment generate ripples of improvement that create a tsunami of reform.
is already wired today.
Health IT can drive better patient outcomes
the foundation that
For millions of Medco members, we already have the ability to cross-reference pharmacy data with medical data. That allows for more comprehensive treatment of chronic and complex conditions. First, we can utilize the data to stratify each of Medco’s 60-plus million members to identify their dominant chronic disease and determine who are undergoing longterm treatment. Then Medco Therapeutic Resource Centers® (TRCs), our proprietary pharmacy practice where specialist pharmacists focus on the treatment of a particular disease, care for those patients. Specialist pharmacists work in much the same way as a physician who specializes in a particular area of medicine and who provides deeper clinical support than a general practitioner.
Pharmacy is wired today . . . e-Prescribing hub Independent pharmacies
Retail chains
Physician and member contacts
Pharmacy administration
Knowledge engine
Medco services (DUR, TRCs, etc.)
In 1990, federal law was enacted to wire pharmacies from end to end, nationwide. Healthcare reform should build on that foundation.
The Medco Pharmacy
Automatic dispensing for greater accuracy
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Powering care specific to a condition For example, Medco currently services approximately 5 million patients for diabetes. When these patients call in, they reach our diabetes therapeutic resource center, where our pharmacists interface with patients and physicians to close gaps in care unique to diabetes treatment.
Medco specialist pharmacists access integrated data to identify and close gaps in care.
How do we close gaps in care? Again, using diabetes as an example, we match individual patient care to evidence-based protocols. This supports physicians, who understandably have difficulty keeping up with the increasing volume of scientific evidence, and patients, who often don’t understand or don’t follow their doctor’s guidance. Medco’s specialist pharmacists are empowered by access to integrated data— viewing a patient’s progress relative to national protocols and identifying and closing gaps in care that are tied to omissions or compliance. Of course, if the entire healthcare system were wired, we could also deliver this information to doctors at the point of patient service. This would allow doctors to both model their practice against their peers and track their patient’s compliance —addressing issues directly, as appropriate. Taking this to the next level, the wired platform would enable payors to reimburse doctors for performance—finally providing the ability to value and compensate the physician’s diagnosis, treatment, and counseling skills, which are critical in raising the standards for quality care.
Medco Therapeutic Resource Centers
Care for patients with chronic and complex conditions
Patients Rx Billions
Diabetes
Cardiovascular
5mm $ 9.9
11mm $ 14.8
u u
Pulmonary
Neurology Psychiatry
Oncology Immunology
5.8mm 10.3mm 1.1mm $ $ $ 6 3.5 4.3
Rare and Specialty
469,000
7.9
$
Medco Therapeutic Resource Centers— Pharmacies that specialize in treating a specific condition Medco specialist pharmacists — Advanced training, unparalleled experience
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In the absence of this elevated level of care and counseling, patients may develop more severe conditions, which could cause them to wind up in the emergency room or in bed for an extended hospitalization due to complications from their underlying chronic or complex condition. That is the most costly outcome in both financial and human terms.
Wiring healthcare helps physicians provide better care and empowers patients.
Medco approach closes gaps in care Wiring healthcare creates transparency and accountability that helps physicians provide better care, ensures that payors receive greater value, and empowers patients to become educated and engaged healthcare consumers. The early learnings from our advanced pharmacy model were derived from an analysis of 600,000 members among six large Medco clients. The results surpassed even our high expectations: • In cases where patients were not following their doctor’s orders, we closed 76 percent of all compliance gaps for diabetes patients; we closed 74 percent of all compliance gaps for pulmonary patients; and we closed 75 percent of all compliance gaps for cardiovascular patients. •W e also tracked omissions—where the physician isn’t following an accepted national protocol. As you might imagine, that requires changing a physician’s behavior. For diabetes care, we closed 18 percent of those gaps; for cardiovascular care, we closed 24 percent of those gaps; and for pulmonary care, we closed 57 percent of those gaps.
How a wired system improves diabetes care
Patients with diabetes under Medco Therapeutic Resource Center care outperformed diabetes patients under traditional pharmacy care.
Diabetes is generally accepted as one of the most pervasive, preventable, and treatable chronic conditions affecting the American population—growing at rates considered by many to be epidemic and accounting for about 10 percent of all healthcare spending. By leveraging its advanced pharmacy model, Medco is driving higher adherence rates with evidence-based standards of care for diabetes, which results in better clinical outcomes and reduced medical costs for payors. Frequent blood glucose testing and adherence to recommended therapies are proven to control diabetes and prevent complications. A recent Medco analysis compared compliance with evidence-based diabetes quality-of-care metrics for patients enrolled in the Medco Diabetes Therapeutic Resource Center with patients receiving traditional pharmacy care. Key findings included: • M ore than 78 percent of TRC patients were adherent to their diabetes medications, com pared with only 56.5 percent. • More than 83 percent of TRC patients with diabetes were adherent to antihypertensive medications, compared with 65.4 percent. • M ore than 80 percent of TRC patients with diabetes were adherent to cholesterollowering medications, compared with 62.4 percent. • Of patients with diabetes needing to be on a cholesterol-lowering medication, 76.6 percent of TRC patients were on a cholesterol medication, compared with 63 percent.
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A wired system facilitates better adherence Helping patients follow care protocols
Compliance Rates
Key diabetes metrics
Average blood sugar, lower to prevent amputation, blindness, kidney failure, nerve damage, heart attack, and stroke Assess average blood sugar (A1C test in past year) M**
69.2%
Insulin users monitoring blood sugar with test strips MP
65.3%
Adherence—diabetes medication
P
78.1%
Prevent ER visits for insulin users
M**
80.2%
Frequent blood glucose testing and adherence to recommended therapies are proven to control diabetes and prevent complications. Patients under the care of the Medco Diabetes Therapeutic Resource Center consistently had higher compliance rates with evidence-based quality-of-care metrics than diabetes patients receiving traditional pharmacy care.
Blood pressure, lower to prevent heart attack, stroke, and kidney failure 77.0%
Use ACE inhibitor/ARB (>55) Use ACE inhibitor/ARB (% BP med users, 18–55)
P
86.8%
Adherence—any BP medication
P
83.3%
Cholesterol, lower to prevent heart attack and stroke Assess LDL—cholesterol (obtain LDL-C test)
M**
63.8%
Use cholesterol medication
P
76.6%
Adherence—cholesterol medication
P
80.5%
** Medical measures are limited to members with diabetes under 65 years of age due to data limitations typically observed in Medicareeligible populations. M = Measured using Medical Claims Data; P=using Pharmacy Claims Data; MP = using either Medical or Pharmacy Claims Data
Better adherence drives superior outcomes
Healthcare cost per diabetes patient per year Patients who adhered to their treatment regimen 80 to 100 percent of the time incurred significantly lower medical costs than those who were less adherent.
$55 $8,812 $350
$165
$285
$6,959
$6,237
$404 $5,887
$763
Drug cost Medical cost
$3,808
1–19
20–39
40–59
60–79
80–100
Patient adherence level (%) Source: Sokol MC, McGuigan KA, Verbugge RR, Epstein RS. Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost. Medical Care. 2005; 43: 521-530.
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Advancing the new science of pharmacogenomics Medco’s ongoing research into pharmacogenomics—using a patient’s unique DNA patterns to select the right medicine at the right dose—drives home another important aspect of wired healthcare: reducing the time it takes for scientific fact to be incorporated into routine medical practice.
It takes about 17 years for a protocol to become broadly adopted. Medco is challenging that timeframe.
Generally, it takes about 17 years for a proven protocol to become broadly adopted by the medical community. Medco is challenging that timeframe through a collaboration with The Mayo Clinic on research on genetic tests related to warfarin (brand name Coumadin®). Warfarin is the same compound in rat poison, but for humans, when carefully controlled, it’s proven to be an effective and broadly prescribed blood thinner. Nonetheless, dosed imprecisely, complications could be fatal. It takes doctors up to 6 months to properly adjust the dose to a patient’s body chemistry. In that 6-month period, 22 percent of these patients, on average, will be admitted to a hospital, many with a serious bleeding condition or clot. Our work with The Mayo Clinic is designed to determine the effectiveness of a lowcost genetic test to help in setting the precise dose tailored to the patient’s unique genetic predisposition at the onset of treatment—eliminating the guesswork.
Delays in implementing best medical practices
Adoption in clinical practice lags behind evidence by many years Clinical procedure
Years since landmark study
Current rate of use
Flu vaccine
41
55.0%
Thrombolytic therapy
38
20.0%
Pneumococcal therapy
32
35.6%
Diabetic eye exam
28
38.4%
Beta blockers after MI
27
61.9%
Mammography
27
70.4%
Cholesterol screening
25
65.0%
Fecal occult blood test
23
17.0%
Diabetes foot care
16
20.0%
The adoption of procedures proven to improve clinical outcomes can take many years before widespread acceptance among physicians.
Source: Balas EA, Boren SA: Managing Clinical Knowledge for Healthcare Improvement. Yearbook of Medical Informatics 2000, pp 65-70.
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The support systems
Despite the fact that the FDA changed the label in 2007, urging doctors to consider the genetic test before patients receive warfarin, and despite coverage in The Wall Street Journal, The New York Times, JAMA, The New England Journal of Medicine, and other publications— only three in 1,000 doctors contacted by Medco to participate in our study had ever heard of the test. Wiring the system would ensure that doctors receive this potentially life-saving information whenever they write a new prescription for this medicine.
that doctors benefit from
To be clear, doctors want to do what’s best for their patients. The problem is the support systems simply aren’t in place to ensure that they benefit from the latest information at the point of care. The solution to this problem is not a pipe dream: It can be done today.
the latest information
Data mining discovers a dangerous mix
at the point of care.
Wiring healthcare also allows us to measure and monitor for effectiveness. Clinicians at Medco recently took note of a small study in France suggesting that medicines routinely used to control heartburn, called proton-pump inhibitors (PPIs), potentially counteract the anticlotting effect of clopidogrel (brand name Plavix®) the third largest-selling drug worldwide.
aren’t in place to ensure
We have millions of patients using heartburn medicines. So we checked our data and discovered that using PPIs in combination with clopidogrel increased the risk of a heart attack by 74 percent and related cardiovascular events by 50 percent overall.
Health IT empowers clinical insight
Evidence-based research will improve outcomes
The Wall Street Journal. November 12, 2008.
By mining its data, Medco discovered that using heartburn medications (PPIs) in combination with the blood thinner clopidogrel increased risk of heart attack by 74 percent and related cardiovascular events by 50 percent overall.
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After we published these findings, and others found similar findings, the FDA issued a cautionary notice to all physicians. Up to that time, using a PPI along with clopidogrel was an accepted protocol—proof that protocols will change over time as we constantly examine new data in a continuous learning loop.
Wiring healthcare hasn’t been well explained.
So, you may ask, with such a compelling argument for wiring healthcare, why hasn’t it already been done? It simply hasn’t been well explained. The general public doesn’t understand it. Even physicians don’t appreciate the real power of Health IT, including my own father.
Obstacles to Health IT reform One of the biggest obstacles to advancing reform that will usher in meaningful progress in Health IT is the “fear factor.” One of those “fears” concerns securing patient information. Today we trust our most sensitive financial data to online systems; and the government already warehouses our detailed personal information through the Social Security System, the IRS, and other agencies. A government-sanctioned, secure, and centralized data warehouse, with appropriate access restrictions, seems the best solution for creating and maintaining a trusted patient-centric repository that aggregates all health information real-time. Defining and advancing standards that will underpin Health IT should be a top priority in Washington D.C.
Barriers to success
Technology “fear factor”
Cost
Desire to protect status quo
The need for standards, the need for Congress to fully recognize the potential savings of Health IT, and resistance to change are three barriers to Health IT reform.
• Interoperability standards • Privacy concerns • Stewardship • I nvestment without standards is the enemy of innovation and effective implementation • L egislative scoring takes a linear and therefore limited view of Health IT savings ($12.5 billion over 10 years)
Resistance to: • Adopt technology • Embrace protocol-based practices • Fix medical liability issues
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Secondly, the scoring systems used by Congress to measure financial impact need revising to accurately credit the full value of Health IT. Currently the government scores Health IT as a $12.5 billion opportunity over 10 years. This evaluation is limited to administrative savings for a few government programs and it simply misses the incredible savings that cross all corners of the healthcare delivery system, which is largely a private-payor paradigm.
The scoring systems used by Congress need revising to accurately credit the value of wiring healthcare.
Finally there is inertia in any system, a true desire to protect the status quo; and healthcare is no exception. Physicians, privacy groups, insurance interests, trial lawyers, private employers, politicians, providers, suppliers, and others feel threatened by change—for a variety of reasons. In the past, these groups have nodded to the concept of reform but all too often find reason to subvert the effort when they are asked to change their business model. To address such resistance, government needs to realign physician incentives. Since doctors bear a significant cost for wiring healthcare, reimbursement formulas need to be rethought to promote implementation of this technology.
As I have outlined, a series of benefits that improve safety, raise the quality of care, and reduce waste has the potential to leverage the synergies of Health IT in ways that no one can even imagine today. That’s the paradigm of technology—cascading benefits and regenerative innovation.
Technology has the power and potential to drive improvement that is transformative.
Government and the private sector must reinvent. Wiring the system is the first crucial step in that journey. As President Obama said recently, “Healthcare reform cannot wait, it must not wait, and it will not wait.”
Never at any time in my adult life have I perceived more energy around the need and desire to reform healthcare. I share the Obama administration’s confidence in the power and potential of technology to drive improvement that is not just incremental, but transformative. And I would humbly suggest the best path forward is a phased approach with a succession of building blocks.
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David B. Snow, Jr., Chairman and Chief Executive Officer, Medco, is a healthcare industry veteran, innovator, and entrepreneur who has created and implemented solutions to manage the rising costs of healthcare for 30 years. Mr. Snow joined Medco, one of the nation’s leading pharmacy benefit managers (PBMs), in March 2003 as president and CEO, and added chairman to his title in June 2003.
David B. Snow, Jr. Chairman and Chief Executive Officer Medco
Prior to Medco, Mr. Snow was president and chief operating officer at Wellchoice, Inc. (formerly Empire BlueCross BlueShield). Throughout his expansive career, he has served in executive leadership roles for several companies including Oxford Health Plans, American International Healthcare, Inc., and US HealthCare, Inc. He also co-founded and served as president and CEO of Managed Healthcare Systems, Inc., which was later renamed AmeriChoice. Mr. Snow earned a master’s degree in healthcare administration from Duke University in 1978 and holds a bachelor’s of science degree in economics from Bates College (1976).
About Perspectives Perspectives is a series of presentations by Medco executives, offering insights into the most pressing matters concerning healthcare. Past issues have addressed healthcare reform and other subjects confronting patients, employers, health plans, government officials, and drug makers — virtually every one of us that is affected directly by the myriad of issues related to prescription healthcare. The series provides insight into the issues of the day and stimulates discussion around what we are all confronting across the national healthcare landscape.
About Medco Medco Health Solutions, Inc. (NYSE: MHS) is pioneering the world’s most advanced pharmacy®, and its clinical research and innovations are part of Medco making medicine smarter™ for more than 60 million members. With more than 20,000 employees dedicated to improving patient health and reducing costs for a wide range of public and private-sector clients, and 2008 revenue exceeding $51 billion, Medco ranks 45th on the Fortune 500 list and is named among the world’s most innovative, most admired, and most trustworthy companies.
For more information, go to www.medcohealth.com. The Medco Perspectives series includes the following: u
u
u
Closing Gaps in Care with Advanced Pharmacy Kenneth O. Klepper, President and Chief Operating Officer, Medco A Prescription for National Healthcare Reform David B. Snow, Jr., Chairman and CEO, Medco The Future of Pharmacy: Personalized, Specialized, and Consumer-Driven Robert S. Epstein, M.D., M.S., Chief Medical Officer, Medco
Legislating Change: Opening the Door to Generic Opportunities David B. Snow, Jr., Chairman and CEO, Medco
u
Medco and Medco Therapeutic Resource Centers are registered trademarks and Medco making medicine smater is a trademark of Medco Health Solutions, Inc. © 2009 Medco Health Solutions Inc. All rights reserved. EME2236