WorldatWork You and Your PBM: Improving Discounts, Fees and Rebates, and Beyond. Kristin Begley, Pharm.D. Principal

Transcription

1 WorldatWork You and Your PBM: Improving Discounts, Fees and Rebates, and Beyond Kristin Begley, Pharm.D. Principal

2 Presentation Overview The future of drug trend Prescription drug management levers: Contracting Plan design strategies Clinical Cost Management strategies Emerging tactics, including: Pricing transparency, specialty management, point-of-sale rebates, generous generics, value drug optimization, and compliance management 2

3 The Future of Drug Trend Spending on prescription drugs is likely to accelerate over the next several years Increases driven primarily by faster utilization growth for new and existing drugs Source: Centers for Medicare & Medicaid Services 3

4 Prescription Drug Management Levers Strategic Lever Contracting Benefit Design Clinical Management Request for proposals (RFP) Cost shift (e.g., deductibles) Prior authorization Carve in vs. carve out Multi-tier copays Drug utilization review Prevalent Tactics Limited network or 90 days Rebate optimization Coinsurance Mandatory generic dispensing Step therapy Physician profiling Deal benchmarking Mandatory mail Quantity limitations Audit Consumer-based plans Emerging Tactics Transparency in pricing AWP update Coalitions and consortiums Rebates at point of sale Generous generics Value-based design Value drug optimization Compliance management Specialty drug management On-site clinics Pharmacogenomics 4

5 The Pharmacy Deal How do you know if your deal is competitive? How will the AWP settlement affect pricing? What about coalitions?

6 AWP Settlement and Your Contract The District Court of MA recently approved a settlement in the AWP lawsuit against First DataBank and McKesson Corp. Most immediate impact is a one-time adjustment (or roll back ) to the AWP pricing index used in your PBM or health plan contracts, scheduled to occur in September 2009 PBMs will attempt to modify or renegotiate the AWP-based discount guarantees in your contracts Because the roll back does not affect all drugs, the financial impact will vary from client to client based on claims experience; a detailed independent claims analysis should be conducted to ensure that the PBM s proposed discount changes result in economic neutrality for all parties involved Hewitt has developed a financial model to evaluate the cost neutrality of proposed discount changes, using actual date-matched First DataBank AWP data The underlying price of drugs is not directly impacted by the roll back event; what is changing is the metric used to guarantee drug pricing through your PBM or health plan Longer term, we expect AWP to be discontinued, based on First DataBank s stated intention to cease publishing the index within two years of the settlement date Hewitt has lead the industry in discussions regarding alternate pricing strategies in the event of the dissolution of AWP 6

7 Emerging Tactic: Pricing Transparency Disclosure of Retail Spread Disclosure of Rebate Retention 100% Pharma Revenue Pass-Through Pass-Through Specialty Pricing Unrestricted Audit Rights Traditional Pricing Relationship Completely Transparent Relationship Retail Contract Audit Rights 100% Rebate Pass-Through Point-of-Sale Rebates Acquisition Cost Pricing at Mail Transparency encourages competition and consumerism in a black box marketplace, and aligns incentives between PBMs, patients, and employers 7

8 First You Measure Prescription Benefits for XYZ Company Ranking and Benchmarking Current Deal Net Percentile without Rebates Net Percentile with Rebates Compared to to Large Populations (N (N = 87) = 87) 3.4% 11.5% Compared to to Entire Database (N (N = 219) = 219) 6.8% 24.2% Current Percentile Improvable Percentile Improvable Retail Discounts Effective Brand AWP 14.0% 6.9% 85.1% 12.8% 73.5% Effective Generic AWP 35.0% 3.4% 87.4% 2.7% 75.3% Retail Dispensing Fees Net Brand $ % 52.9% 48.4% 44.3% Net Generic $ % 46.0% 55.7% 38.8% Mail Order Discounts Effective Brand AWP 22.0% 34.5% 59.8% 53.4% 40.2% Effective Generic AWP 57.0% 81.6% 18.4% 82.6% 15.1% Mail Order Dispensing Fees Net Brand $ % 0.0% 100.0% 0.0% Net Generic $ % 0.0% 100.0% 0.0% Admin Fees Net Retail $ % 0.0% 100.0% 0.0% Net Mail $ % 0.0% 100.0% 0.0% Net Per Claim Retail Rebates $ % 20.7% 83.1% 16.4% Net Per Claim Mail Order Rebates $ % 9.2% 94.1% 5.0% 8

9 First You Measure Core pricing terms that drive total pharmacy cost: Other pricing terms that can impact the bottom line: Discounts off AWP Rebates Dispensing fees Administrative fees Specialty discounts and dispensing fees Clinical program fees Implementation credits Vendor interface charges 9

10 Time for Contracting And the Devil Is in the Details It is not all about the numbers! Contract language can directly impact the competitiveness of your deal: Definition of brands and generics Inclusion/exclusion of single-source generics in pricing Days-supply limitations on rebates Guarantee offsetting across pricing terms PBM s unilateral right to modify pricing in the event of: Changes in AWP Action by a pharmaceutical company Just about any unforeseen circumstance! 10

11 Where PBM Revenue Comes From ( Educated Guess ) 100% 75% Retail Drug Pricing Margin Mail Order Drug Pricing Margin Admin Fees 50% Specialty Drug Pricing Margin Pharma Rebates 25% 0% Other Pharma Revenue Clinical Programs 9 Yrs Ago 6 Yrs Ago 3 Yrs Ago Today Less reliance on retail drug pricing margin and direct rebates More reliance on other pharma revenue and specialty drug pricing margin 11

12 Emerging Tactic: Coalitions and Consortiums Consultant-Led Coalitions Client-Led Coalitions HR-Policy s TIPPS Coalition Primary Purpose Vendor Alignment Vendor Selection and Pricing Negotiations Vendor Contracting Pricing Format Ongoing Consulting Services Coalition-based purchasing of PBM services, using a preferred PBM vendor selected by Hewitt Typically a single-vendor arrangement, but may include multiple vendors Handled collectively by consultant, no RFP necessary Three-way contracts typically held between vendor, member company, and consultant Coalition-based purchasing of PBM services, using a preferred PBM vendor selected by a controlling client or group of clients Typically a single-vendor arrangement Handled by the client or clients, usually with support from a consulting firm Two-party contracts held between vendor and member companies Coalition-based certification of a group of PBM vendors, based on the transparency of their business practices Multiple vendors are certified Handled independently by member companies via RFP; pricing will vary by member company Two-party contracts held between vendor and member company, coalition not directly involved Can be transparent or traditional Can be transparent or traditional Fully transparent Ongoing consultant services may or may not be included, on a bundled or fee-for-service basis Consultant may or may not be engaged for ongoing management, on either a commission or flat-fee basis Not included, handled independently by member companies and their consultants 12

13 Plan Design and Clinical Cost Management Are your members taking the most cost efficient drug? Are they taking their drugs at all?

14 Prominent Plan Design Strategies Brand-Only Deductible Coinsurance Design With POS Rebates >3-Tier Design Generous Generics 90-Day at Retail Coupon/Lettering Campaign Decision Support Tools Copay Waivers TMAC/Reference-Based Pricing/Reverse Copay High Performing Formulary Value-Based Plan Design Compliance-Based Member Cost Share Specialty Drug Analysis Consumer-Driven Plan Design Step Therapy Prior Authorization Mandatory Mail Mandatory Generic Age Edits and Quantity Limits Consumer Investment Savings Potential 14

15 Emerging Tactic: Point-of-Sale (POS) Rebates Leads to the adjudication of true net cost of drugs when calculating coinsurance amounts In a coinsurance model, issues may arise if rebates are not shared because the member may technically be paying more than the agreed upon coinsurance amount Employer with target member cost share of 25%... With POS Rebates Drug Price $100 Without POS Rebates Rebate $ 20 $ 20 True Net Cost of Drug $ 80 $ 80 Member Coinsurance (25%) $80 x 25% = $20 $100 x 25% = $25 Actual Member Cost Share (% of True Net Cost) 25% $100 31% 15

16 Emerging Tactic: Generous Generics Approximately 60% of drugs have a generic equivalent 80% of therapeutic categories have at least one generic drug available Several blockbuster drugs lost patent protection including: Zocor, Ambien, and Zyrtec Assigning a very low copay for generic medications can create a significant financial incentive, driving utilization to low cost generic drugs To maximize the shift in utilization, the copay spread between generic and brand medications should be significant 16

17 Emerging Tactic: Value Drug Optimization An average client with 20,000 employees spends $135 million on health care Approximately 20% or $27 million is spent on prescription drugs We typically identify 20% 30% savings opportunity for optimizing drug mix Value drugs: the most clinically cost-effective drug for treating given condition How important are the following strategic priorities in your efforts to increase the value of your prescription drug benefit? Focusing on Substituting Generic Drugs for Brand Name Drugs 77% 19% 3% 1% Very Important Somewhat Important Somewhat Unimportant Very Unimportant Source: The Road Ahead: Emerging Health Trends Survey

18 Why Manage Drug Mix? Cost Per Claim of the Most Common Stomach and Ulcer Medications Drug Type Cost for 30 Days Aciphex Brand $134 Nexium Brand $142 Prevacid Brand $146 Prilosec Brand $132 Protonix Brand $108 Omeprazole Generic $ 28 Famotidine Generic $ 10 OTC Prilosec OTC $ 22 18

19 Sample Value Drug Report Card PMPM 1 PMPM Saving Condition Actual Cost Actual Cost Targeted Cost Targeted Cost Opportunity Stomach and Ulcers $ 6,670,254 $2.57 $2,479,471 $0.96 $4,190,783 Cholesterol Lowering $10,300,489 $3.97 $7,220,232 $2.78 $3,080,257 Asthma $ 4,948,141 $1.91 $3,540,513 $1.36 $1,407,628 Allergies $ 2,709,289 $1.04 $2,363,030 $0.91 $ 346,259 Anti-Infectives $ 5,433,126 $2.09 $5,137,104 $1.98 $ 296,022 Narcotics $ 5,695,632 $2.20 $5,695,632 $2.20 $ 0 High Blood Pressure $ 8,205,122 $3.16 $8,205,122 $3.16 $ 0 Diabetes $ 795,769 $0.31 $ 795,769 $0.31 $ 0 Depression $ 5,907,389 $2.28 $5,907,389 $2.28 $ 0 Anti-Arthritis $ 1,451,247 $0.56 $1,451,247 $0.56 $ 0 1 Per member per month In this example, $9 million in savings can be achieved by managing the utilization efficiency (drug mix) for cholesterol lowering, stomach and ulcers, asthma, and allergy 19

20 Understand Results, Implement Solutions Drug Class Low Moderate Aggressive Considerations Stomach and Ulcer Cholesterol Lowering Allergies Member/doctor communications Copay incentives Over-the-counter (OTC) coupon Member/doctor communications Copay incentives Member/doctor communications Copay incentives OTC coupon Mandatory generic Step therapy Prior authorization Mandatory generic Step therapy Mandatory generic Step therapy Prior authorization Drop class coverage (OTC available) Quantity limits (weeks of therapy/year) Generic-only coverage Drop class coverage Quantity limits OTC Prilosec available 3 generic statin products available Second most utilized drug (Zocor) now has a generic OTC Claritin and Zyrtec and generic Allegra available 20

21 Trend: Direct Medical Costs The Tip of the Iceberg Direct Costs Medical Claims Pharmacy Claims Indirect Costs Absenteeism Short-Term Disability Long-Term Disability Presenteeism Goal = healthier, more productive workforce + more cost-effective health care 21

22 Emerging Tactic: Compliance Management Compliance to long-term therapy for chronic diseases averages 50% in developed countries 1 Only 25% of prescriptions for chronic conditions are refilled after one year 2 Two-thirds of all Americans fail to fill (compliance) their prescription medicines at the appropriate time 3 Almost 29% of Americans stop taking their medicine before it runs out 3 Drugs don t work in patients that don t take them. C. Everett Koop, M.D. 1 World Health Organization Taskforce for Compliance American Heart Association 22

23 Noncompliance Increases Medical Spend: Diabetes $10,000 $9,000 $55 Average Expenditures Per Year $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $8,812 $165 $6,959 $285 $404 $6,237 $5,887 $763 $3,808 $1,000 $0 1% 19% 20% 39% 40% 59% 60% 79% 80% 100% Compliance Levels (% Days Supply/1 Year) Medical Prescription Drug Source: M.C. Sokol, K.A. McGuigan, R.R. Verbrugge, R.S. Epstein, Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost, Medical Care 2005; 43:

24 The Impact of Increased Cost Sharing on Utilization Compliance With Statin Therapy Stratified by Mean Prescription Copayment Member cost is only part of the compliance picture Source: Ellis JJ. J Gen Intern Med 2004;19:

25 Sample Compliance Results Therapeutic Class Unique Members 1 Total Claims Total Dollars Average Compliance 2 Target Compliance 2 Percentage of Patients at Target Compliance 2 Cholesterol Lowering 429,075 $2,017,545 $321,527,073 83% 85% 66% Depression 275,600 $1,249,911 $141,506,509 74% 90% 47% Diabetes 136,496 $ 921,414 $ 90,067,834 86% 90% 68% High Blood Pressure 640,198 $5,083,560 $263,234,115 88% 85% 77% Chronic Respiratory 38,235 $ 89,765 $ 16,827,167 50% 85% 24% HIV/AIDS 2,326 $ 23,303 $ 20,012,758 89% 95% 75% Hepatitis B 323 $ 1,604 $ 1,259,524 84% 95% 55% Hepatitis C 678 $ 4,456 $ 7,584,755 80% 95% 62% Immunosuppressants 5,456 $ 33,228 $ 16,089,583 81% 95% 55% Osteoporosis 106,391 $ 424,577 $ 58,429,823 77% 85% 56% Alzheimer s Disease 17,795 $ 105,081 $ 22,138,818 82% 90% 62% 1 Unique members utilizing per class (may overlap into other classes) 2 Compliance scores adjusted through December 31 (prescription drug quantities after December 31 are removed from the analysis); compliance scores based on utilization within a therapeutic class (not individual drugs as members can change drugs within the therapeutic class) In this case, opportunities exist to improve compliance in all categories 25

26 Emerging Tactic Value Based Design VBD compliance THERAPEUTIC CLASS 2008 UNIQUE MEMBERS 2007 UNIQUE MEMBERS MEAN POPULATION COMPLIANCE 2008 AVERAGE COMPLIANCE 2007 AVERAGE COMPLIANCE TARGET COMPLIANCE % 2008 PATIENTS AT TARGET COMPLIANCE Significant positive results demonstrated with 2% or move improvement for 7 of the 9 categories assessed Hepatitis B/C excluded for clinical rationale and numbers affected % 2007 PATIENTS AT TARGET COMPLIANCE High Blood Pressure % 83% 80% 85% 67% 64% Cholesterol Lowering % 81% 79% 85% 61% 59% Depression % 74% 71% 90% 45% 42% Diabetes % 80% 77% 90% 56% 54% Chronic Respiratory % 40% 41% 85% 14% 14% Osteoporosis % 74% 70% 85% 54% 47% Immunosuppressants % 82% 72% 95% 59% 39% HIV/AIDS % 86% 78% 95% 77% 56% Hepatitis C % 90% 84% 95% 75% 80% Alzheimers Disease % 77% 91% 90% 57% 83% Hepatitis B % 52% 83% 95% 0% 0% Green equals two percent or more improvement Yellow equals two percent or more reduction or large population gain for condition 26

27 Emerging Tactic: Specialty Drug Management There are over 400 drugs in the specialty and biotech pipeline with 70% requiring administration by a health care professional Update slide 45% of drugs in clinical trials for new indications are specialty drugs By 2010, half of FDA approvals will be specialty drugs 27

28 ABC s of Specialty Management Access to Drugs Benefit Design Care Management Distribution management Delivery/fulfillment Ancillary supplies Design flexibility Appropriate member responsibility for highcost medications Managing plan design across medical and pharmacy benefit Creating incentives for member compliance through preferred distribution channels Participant education and support Clinical and outcomes reporting Therapy optimization disease management Case management 28

29 Goals of Specialty Drug Management Easy access and use of specialty pharmaceuticals and reduced drug spend Increase patient compliance through enhanced condition management to avoid wastage Affordable and easy access to high quality care Offer incentives to members and providers to access the most efficient delivery system Develop a migration plan to support the move to the most efficient delivery system 29

30 Pharmacy Management Mission

31 Pharmacy Management Mission To leverage the best clinical outcome for patients who utilize medications through the combined integration of the following: Aggressive procurement strategies and due diligence through audit Continual plan management through measurement and the development of innovative design approaches Optimized medication selection (drug mix) and member choice The holistic management of total medical spend 31

32 Additional Information Visit our Linkedin group or me at if you d like more information about maximizing pharmacy management Contracting Plan design Clinical cost management 32