Insights into pharmacy benefit management, drug trend and the future

Transcription

1 Insights into pharmacy benefit management, drug trend and the future 1 Where does your health care dollar go? 2 Pharmacy share of total health spend 25% 21% 20% 19% 15% 10% 10% 5% 0% Retail Drugs as a Share of National Health Spending Retail Drugs as a Share of Employer Insurance Benefits Retail Drugs as a Share of Employer Insurance Benefits with Rebates Source: Kaiser Family Foundation analysis of data from the Centers for Medicare and Medicaid Services and Truven Health Analytics 3 1

2 National pharmacy spend 60% 50% 50% 42% 40% 30% 30% 25% 20% 10% 0% 18% 14% 10% 5% 4% 2% Other Medicare Medicaid Private Insurance Out-of-pocket Distribution in 2005 Distribution in 2017 Source: Kaiser Family Foundation analysis of data from National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group 4 Per capita retail drug spend $1,200 $1,000 $800 $600 $400 $200 $ Inflation Adjusted Retail Price Retail Rx drug spending (nominal) Source: Kaiser Family Foundation Analysis of National Health Expenditures Account 5 Three key drug cost drivers UTILIZATION DRUG MIX UNIT PRICE 6 2

3 Cost drivers: Price vs. utilization 14% 12% 10% 8% 6% 4% 2% 0% -2% Price Index Quantity Index Source: Kaiser Family Foundation analysis of Bureau of Economic Analysis data 7 Significant impact of drug mix % OF PRESCRIPTIONS GENERIC % OF TOTAL NET PHARMACY COST SPECIALTY BRAND BRAND GENERIC SPECIALTY 91.27% 8.13% 0.6% 2018 YTD Q3: Self-insured + fully insured large commercial employer groups $ % $280 37% $4,680 40% 8 Specialty drugs driving trend 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% % -10.0% Specialty Drug Trend Traditional Drug Trend Overall Drug Trend Source: IQVIA, Medicine Use and Spending in the U.S., April 2018; IQVIA Institute of Human Data Science. 9 3

4 Growing specialty drug share 80% 70% 60% 50% 40% 30% 20% 10% 0% Specialty vs Traditional Spend 79% 76% 72% 67% 65% 60% 60% 40% 40% 33% [VALUE] 28% 21% 24% Specialty Spend Traditional Spend Source: HealthPartners Commercial Pre-rebate data 10 Top drug spend under pharmacy Top Condition by PMPY Spend Inflammatory Conditions Diabetes Oncology Multiple Sclerosis HIV Pain/Inflammation Attention Disorders Asthma High Blood Pressure High Blood Cholesterol Source: Kaiser Family Foundation analysis of data from Express Scripts 2017 Drug Trend Report 11 Drugs under the medical benefit 12 4

5 Drugs covered under medical benefit Administration Injectable Treatments Cost Administered by a health care provider in a doctor s office, hospital, ambulatory infusion center, patient s home Typically injectable or intravenous drugs Majority of spend is for specialty drugs to treat autoimmune conditions, multiple sclerosis, and cancer High cost in aggregate and per patient cost 13 Total integrated specialty drug PMPM 68% of specialty drug spend is under the pharmacy benefit $ % $60.00 $50.00 $40.00 $30.00 $20.00 $10.00 $- Rx PMPM Medical PMPM Total PMPM 2Q2017 2Q Top 5 specialty conditions Integrated specialty PMPM * Top 5 Specialty Conditions $25.00 $20.00 $15.00 $10.00 $5.00 $- Chronic Inflam Disorder Oncology Multiple Sclerosis Blood Modifiers Immune Globulins Medical PMPM Rx PMPM Total PMPM *HealthPartners commercial book of business pre-rebate 2Q

6 Managing pharmacy spend 16 Integration vs. siloes Industry integration CLINIC/PROVIDER SPECIALTY PHARMACY RETAIL PHARMACY PBM HEALTH PLAN CIGNA + ESI CVS HEALTH + AETNA UNITED HEALTHCARE + OPTUMRX ANTHEM + INGENIORX 17 Low net cost formulary strategy Low cost formulary is 30% lower in annual PMPM $100 $90 $80 $70 $89.58 $90.66 $68.03 $69.95 $60 $50 $40 $30 $20 $10 $ Low Cost Formulary INDUSTRY AVERAGE** *2017 HealthPartners commercial LG FI & SI **2017 Trend Reports Commercial LOB: ESI & CVS 18 6

7 Rebates available for certain drugs TOP 10 THERAPEUTIC CLASSES: HEPATITIS ANTICOAG 2% 3% MULTIPLE SCLEROSIS 4% GROWTH STIMULANTS HORMONES 7% 5% DIABETIC SUPPLIES 9% ASTHMA 12% OPHTHALMIC S 1% Other (43) 8% DIABETES 32% CHRONIC INFLAMMATO RY DISEASE 17% IN 2017, THE TOP 5 OF 53 TOTAL THERAPEUTIC CLASSES ACCOUNT FOR 86% OF TOTAL REBATES 19 Cost of rebate focused formulary Dexilant NET COST DIFFERENCE lansoprazole omeprazole 673% to 3,000% increase Cost: $ per month supply Average rebate: 50% ($135) Lansoprazole: $17.47 per month supply Omeprazole: $4.32 per month supply 20 Utilization management Prior authorizations Quantity limits Step edits 59,200 reviews < 1% of prescriptions $102 M savings 29% denials $8.90 PMPM 21 7

8 2018 top prior authorization drugs DRUG NAME FORMULARY DENIAL % PROJECTED SAVINGS AVERAGE COST/RX AV COST ALTERNATIVE Adalimumab F-PA 9% $9,980,485 $5938 $27 (Humira) Stelara Medical PA 14% $3,751,109 $6850 $27 Remicade Medical PA 7% $2,186,960 $3000 $27 Enbrel F-PA 4% $1,958,773 $5068 $27 Saxenda NF-PA 31% $1,712,421 $1178 $0 Xolair Medical PA 16% $1,381,237 $3158 $230 Cialis NF-PA 46% $955,435 $366 $21 68:1 ROI 22 Leveraging lower cost site of care Maximize negotiated provider contracts and offer more convenient sites of care HOSPITAL $ $ $ CLINIC $ $ HOME $ $ If hospitals renegotiate, members remain $ $ RESULTS: Significant reductions in total allowed and positive member experience 23 Coupon accumulator programs These programs help ensure that all insured group members are treated fairly STANDARD PROCESS COPAY ACCUMULATOR PROGRAM TOTAL COST PAID FOR A PRESCRIPTION PLAN MEMBER Amount Applied to Accums PLAN COUPON ACTUAL MEMBER PLAN COUPON ACTUAL MEMBER Amount Applied to Accums Accumulators: Deductible, Annual Out of Pocket 24 8

9 What can you do? 25 1 in 4 have difficulty with drug cost Very difficult, 9% Don't have to pay, 1% Somewhat difficult, 17% Very easy, 45% Somewhat easy, 28% Very easy Somewhat easy Somewhat difficult Very difficult Don't have to pay Source: Kaiser Family Foundation Health Tracking Poll (conducted Sept 14 20, 2016) 26 Pharmacy shopping tools Walgreens CVS Health 27 9

10 Pharmacy shopping tools HealthPartners 28 Drug price survey Percent who favor the following Allowing the federal government to negotiate with drug companies to get a lower price on medications for people on Medicare Making it easier for generic drugs to come to market in order to increase competition and reduce costs Requiring drug companies to release information to the public on how they set their drug prices Limiting the amount drug companies can charge for high-cost drugs for illnesses like hepatitis or cancer Allowing Americans to buy prescription drugs imported from Canada 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Source: Kaiser Family Foundation Health Tracking Poll (conducted April 17-23, 2017) 29 Pricing advocacy positions Bring real drug costs and profits to light Make cost a factor in FDA approval Unshackle government negotiating power for Medicare without cost shifting to private sector End drug company loopholes and abuses Eliminate or limit direct-to-consumer advertising 30 10

11 Where are we headed? Is our current model sustainable? 31 Oncology dominates drug pipeline Source: The Biopharmaceutical Pipeline: Innovative Therapies in Clinical Development. PhRMA.org. Accessed 10/6/ Oncology drug therapy ECONOMIC CHALLENGES New cancer drug costs have increased more than twice the median monthly household income 33 11

12 Oncology drug therapy value Many new drugs have been approved to treat cancer but only some have provided a true benefit Have we turned a corner with immunotherapy? no conclusive evidence that these drugs either extended or improved life for most cancer indications. 34 Gene therapy Cures therapy? Gene augmentation therapy 1990 appropriated funding Mapping human genes 2003 international project complete $2.7B 40 gene therapies by 2022 Source: MIT FoCUS Research Brief, Nov Gene therapy model* ANNUAL TREND IMPACT TO EMPLOYER GROUPS Group Size Cost of 1 Rx MM Additional drug PMPM Drug PMPM Drug Trend Overall PMPM Impact to overall trend 500 $ 800, $ $ % $ % 1000 $ 800, $ $ % $ % 5000 $ 800, $ $ % $ % $ 800, $ 6.67 $ % $ % Impact of one $800,000 orphan or gene drug therapy Self-insured group 5,000 lives required to normalize trend *Model assumes no stop-loss or stop loss amount per beneficiary high and not met by this claim and other 12-month claim expenses

13 Economic challenges The current insurance financial model isn t working in the face of increasing United States health care system costs? HIGHER COSTS FROM SOME INSURED MORE COST TO SPREAD TO ALL INSURED MEMBERS 37 Is there a viable near-term solution? 38 Managing specialty pharmaceuticals What can plan sponsors do to leverage drug value assessments in innovative benefit and formulary designs? 39 13

14 Institute for Clinical and Economic Review (ICER) Independent health technology assessment group whose reviews are funded by non-profit foundation Develop publicly available value assessment reports on medical tests, treatments, and delivery system innovations Use cost-effectiveness analysis to determine value-based price benchmarks Convene regional independent appraisal committees for public hearings on each report 40 Independent appraisal committees sources of funding ICER Policy Summit only 42 14

15 Value-based price benchmarks COST ($) Even more effective & very high cost Cost-effectiveness threshold at $100K QALY Less effective & higher cost More effective & higher cost EFFECTIVENESS (QALYS) Equally effective & lower cost 43 ICER s examples VALUE-BASED PRICE BENCHMARKS DRUG CATEGORY RECOMMENDED DISCOUNT* PCSK9 inhibitors for high cholesterol 50% Psoriasis 5% Multiple sclerosis 25% Rheumatoid arthritis 15% Atopic dermatitis 0% Osteoporosis 50-80% TKIs for lung cancer 0% PD-1s for lung cancer 50% Abuse-deterrent opioids 40% DRUG CATEGORY RECOMMENDE D DISCOUNT* Ovarian cancer PARP drugs 50% Tardive dyskinesia 85-90% Gene therapy for inherited blindness 50-75% Emicizumab for hemophilia A Cost-saving CAR-T for cancer 0% Cystic fibrosis 67-75% Chronic migraine 0% Elagolix for endometriosis 15%-25% Apalutamide for prostate cancer 0% * For new drugs, discount from list price needed to meet common thresholds of cost-effectiveness. For drugs already in use, discount is from post-rebate price 44 ICER assessments Policy makers: Independent evaluation of value and suggested value-based prices figure in multiple proposals Drug makers and payers: Helps negotiation over prices in conjunction with appropriate access Payers and provider groups: Helps guide coverage decisions and pricing negotiations 45 15

16 Value-based assessment application BENEFIT DESIGN AND PAYMENT POLICY Option 1: Special tier, step therapy, or exclusion for drugs whose best negotiated price remains above the value-based price benchmark Option 2: Include drugs on formulary but only pay up to the value-based price benchmark. Any residual gap between price charged and reimbursement is the responsibility of the patient/manufacturer. 46 Questions 47 16