Current Trends in Rx Plan Management

Transcription

1 Current Trends in Rx Plan Management Amy Steinkellner, Pharm.D. Vice President, Clinical Services Medco s Systemed Group Medco is a registered trademark of Medco Health Solutions, Inc Medco Health Solutions, Inc. All rights reserved.

2 Agenda 1 The Prescription Benefit Landscape 2 Drug Trend Observations 3 What s on the Minds of Plan Sponsors 2

3 Plan sponsors in our market are leaders in their industries and have similar challenges Pressure to manage Rx drug costs while maintaining employee satisfaction 73% of plan sponsors report that balancing cost with care is their most important concern Rx drug costs represent about 20%-22% of overall healthcare costs Limited benefits staff who manage multiple benefits Limited time to focus on Rx Benefit managers spend 10% of their day on the Rx benefit Need a strategic plan to manage drug spend and trend Require easy-to-administer solutions with quantified results Source: 9 Leading Trends in Rx Plan Management: Findings from a National Study sponsored by Medco s Systemed Group. Results are from 200 plan managers with between 1,000-15,000 plan eligibles. Completed January

4 Key Findings Today s Landscape Total Respondents (N=1092) Q. 3. Do you (or anyone else in your family covered by this policy) take any prescriptions drugs for a medical condition or conditions that have lasted or are expected to last for a year or longer that is, for a recurring condition? 4

5 The pharmacy benefit management landscape is changing rapidly Aging of America By 2010, number of seniors aged will increase by nearly 50% 1 Seniors spend more than 3 times what younger consumers spend on prescription drugs (more than 30 Rxs each) Impact on Cost S Drug spend inflation and the need to control costs CMS projects drug spend to increase by 6%-9% annually through 2012 S Specialty pharmaceutical growth Continued shift to generics, mail Fastest growing component expected to reach $82 billion in 2010 compared to $33B in brand-name medications with sales of nearly $49 billion scheduled to become available as generics from ,, Rx volume at mail accounts for more than 17% of all U.S. Rx drug sale S S Increased focus on consumerism Emerging expectations of consumers involvement in their own healthcare and the potential savings in overall healthcare spending S Personalized medicine Adverse drug reactions cause 100,000 deaths annually and 2 million hospitalizations. 5 Genetic testing expected to lower total health care costs and minimize adverse reactions 1. U.S. Census Bureau Population Projections Bureau, Release Date January 13, Medco estimates. Excludes $20-$25B in oncology spend. 3. Medco estimates. 5. MayoClinic.com. S 5

6 National healthcare trends ( ) Healthcare cost growth 16% Prescription drugs 14% Hospital care National trends 12% 10% 8% 6% 4% *Projection Sources: Centers for Medicare and Medicaid Services; Drug Trend Report, 2007, pp * 2007* Year 6 Physician & clinical services 2008* 2009* 2010* 2011* 2012*

7 Robust specialty drug pipeline Over 400 drugs in development* Infectious Diseases 50 Autoimmune disorders 44 AIDS/HIV Cardiovascular disease Neurologic disorders 17 Diabetes/related 15 Digestive disorders Respiratory disorders Blood disorders Genetic disorders Skin disorders % of drugs in clinical trials for new indications are specialty. By 2010, specialty drug spend is expected to reach $82B compared with $33B in 2006.** Eye conditions 6 Growth disorders Transplantation 4 4 Other 18 *Source: PhRMA 2005 Survey: Medicines in Development, Oct Some medicines are listed in more than one category. Excludes 200 oncology drugs **Source: Medco Estimates. Excludes $20-$25B in oncology spend. 7

8 Generic growth opportunity Nearly $49B brand drugs off-patent (Drug spend in billions, annualized*) 13.5 Zocor Zoloft Pravachol Flonase Mobic 11.6 Prevacid Lexapro Aciphex Topamax 12.5 Lipitor Effexor Protonix 7.2 Norvasc Toprol XL 4.5 Fosamax Risperdal 1.9 Flomax Source: U.S. Drug spend estimates are based on IMS Health data for 2005,compounded amounts prorated for mid-term expirations. Brand drug expirations based on expected patent expiration dates current as of October Changes may occur due to litigation, patent challenges, etc. 8

9 Key Findings 2006 Drug Trend Total Respondents (N=1092) Q. 3. Do you (or anyone else in your family covered by this policy) take any prescriptions drugs for a medical condition or conditions that have lasted or are expected to last for a year or longer that is, for a recurring condition? 9

10 Trend in transition: The Medicare effect Medco Drug Trend 15% 14% 13% 12% 11% 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 14.0% 14.0% 12.9% 10.2% 8.5% 5.4% 2.8% Year Source: Medco data 10

11 Top contributors to drug spend by therapeutic category (2006) Other categories Cardiovascular Musculoskeletal & rheumatology 5.0% 15.4% 23.0% Anti- infectives 7.0% Endocrine & diabetes Respiratory & allergy 7.8% 9.0% 9.8% 23.0% CNS: Neurology, mental health and pain Gastroenterology Sources: Medco data; Drug Trend Report, 2007, p

12 Top therapeutic classes contributing to specialty pharmacy spending (2006) Other 20.5% 25.2% Rheumatoid arthritis* Hepatitis C 4.6% Anticoagulation Anemia 4.6% 5.1% 6.5% 18.0% Multiple sclerosis Growth hormone 15.5% Cancer *The drugs in this class may also be used to treat plaque psoriasis, Crohn s disease, and ankylosing spondylitis. Sources: Medco data; Drug Trend Report, 2007, p

13 Top projected contributors to drug trend ( ) Other categories 20% 24% Cardiovascular Respiratory 6% Musculoskeletal & rheumatology 6% 9% 22% CNS: Neurology, mental health & pain Gastroenterology 13% Endocrine & diabetes Sources: Medco data; Drug Trend Report, 2007, p

14 Emerging trends The healthcare industry is changing - Integration of organizations across industry (CVS/Caremark) - Impact of new regulatory requirements (i.e., Med. D, HIPAA, ERISA) A more complex, more sophisticated benefit to manage - Drug mix is changing -- generics, specialty, and biotech - More creative plan designs evolving Lowering co-pays to remove barriers to compliance Adding a 4 th tier to plan design Consumer Directed Health Plans - New financial models emerging Transparency - Personalized medicine on the horizon Genomics, Nanomedicine 14

15 Warfarin-induced hospitalizations: A strong case for genetic testing CYP2C9 Testing for warfarin metabolism rate may reduce risk for hospitalization associated with hemorrhage or thrombosis. Risk associated with dose adjustment and any hemorrhage/ thrombosis hospitalization event 1 Dose adjustment 1 N 1,214 IP event rate 19.60% Testing may reduce the number of dose adjustments required. 2 or more % - Greater dose adjustments = greater risk for hospitalization Total 1, % FDA Advisory Committee agrees with genetic testing for warfarin 2 Sources:1.Medco data., 2.FDA Advisory Committee; fda.gov/cder/genomics. April 26,

16 Future for healthcare in next 5 to 10 years features personalization Benefits are becoming personalized - Benefit designs member level - Consumer tailored tools and information - Consumer directed health plans 16

17 The future ain t what it used to be. - Yogi Berra 17

18 What s On The Minds Of Plan Sponsors?

19 Medco market study reveals several important trends Surveyed benefits leaders at 200 organizations with 1,000 to 15,000 employees in early 2007 to: - Uncover the concerns, challenges and attitudes employers in our target market currently face in managing their pharmacy benefit. - Understand plans for managing this benefit in the near future. Org Type Completed interviews Under 5,000 5,000+ For Profit 55% 50% 63% Public Sector 20% 26% 10% Union 9% 11% 6% Nonprofit 16% 13% 21% Total Respondents (200) (129) (71) 19

20 Key Finding: Seismic shift in benefit philosophy Five years ago, 63% of plan sponsors were most concerned about ensuring that their members had the broadest possible coverage. Today 73% of plan sponsors report balancing cost with care as their primary concern. % of Respondents 100% 80% 60% 40% 63% 73% 32% Current Prior 20% 13% 15% 6% 0% More concerned about providing broadest coverage Concerned about balancing cost with care More concerned about managing cost Total Respondents (200) Q. 5B. Please record below which one of the statements best reflects your organization s CURRENT benefit philosophy as it pertains to the prescription benefit. Q. 5C. Now consider how your organization s benefit philosophy may have changed over the last five years, record below which one of the statements best reflects your organization s prescription benefit philosophy five years ago? 20

21 Key Finding: Generic strategies expected to yield greatest impact Nearly 70% of plan sponsors believe increasing generic utilization will have the most influence on controlling prescription drug costs in the future. Note that each 1% increase in generic dispensing rate can lower plan costs by.6%. Disease Management Programs CDH Options 7% 6% 19% Rules and Strategies that require or encourage use of mail order 68% Strategies Promoting Generics Total Respondents (N=200) Q. 8. Please rank in order the approaches that you think will have the greatest impact on controlling your prescription drug costs in the future. 21

22 Key Finding: Push for mail gains momentum A majority of organizations plan to implement more strategies to boost mail order in the next 12 to 18 months. 70% 70% 60% 50% 52% 40% 30% 20% 22% 10% 0% Total Respondents (N=200) Implement Mandatory/ Incentive Mail 8% Implement Co-payment Waivers Increase Member Awareness Communications Cost Share that Favors Mail Q. 15. Please record below the specific initiatives employed by your plan to encourage mail order use. Then record the ONE specific initiative you believe is most effective to encourage mail order use 22

23 Key Finding: Striving to create behavior-change Two-thirds of organizations now use wellness and disease management programs. Of those who do not have a disease or wellness management program, many plan to in the next three years. 12% Definitely Won t May or May Not 43% 45% Probably/Definitely Will Total Respondents = 200 Q. 20. How likely are you to implement a wellness/disease management program in the next three years? 23

24 Key Finding: CDH Revolution Slows Despite the hype, there is minor intent to implement a CDH plan option in the next three years. 11% Probably Will Probably or Definitely Will Not 52% 37% May or May Not Total Respondents (N=153) Q. 23D. How likely are you to implement a CDH program in the next three years? 24

25 Key Finding: Trends in the adoption of CDH Plans More than 20% of employers with at least 20,000 employees intend to offer a CDH plan this year. 1 3% 5% of employers with 1,000-15,000 employees intend to implement a CDH plan for the 2008 benefit year. 2 A closer look reveals the consumerism movement is growing through channels other than CDH plans, and includes a focus on member engagement incentives and initiatives. Sources: 1 How to Ensure the Success of Your Consumer-Directed Health Plan. CDHC Solutions, May/June Leading Trends in Rx Plan Management: Findings from a National Peer Study, Medco Health Solutions,

26 Key Finding: Plan sponsors expect to continue to cover Medicare eligibles in the coming years Nearly two-thirds of organizations plan to retain some form of coverage for Medicareeligibles. 100% % of Respondents 80% 60% 40% 67% 69% 63% 59% 80% 83% 69% 20% 0% A Total B Under 5,000 C 5,000+ D For Profit E Public Sector F Union Group G Non-Profit Total Respondents (N=200) Q. 27. Do you plan to CONTINUE COVERING ; or COVER Medicare eligibles during the next 3 5 years? 26

27 How Plan Sponsors Are Controlling Drug Costs 27

28 Today, plan sponsors are focused on four key areas Plan Design Consumerism Specialty Drug Management Total Healthcare Management 28

29 Decreased Utilization Plan Design Prior authorization Duplication of therapy Refill too soon Quantity/duration limits Encourage the use of OTC alternatives 29

30 Decrease the cost of the prescriptions Plan Design Cost Share Discount Rebates Plan Cost 30

31 Move to a lower-cost drug Multi-source brand to generic equivalent Single-source brand to generic alternative 31 Plan Design Non-formulary brand to generic alternative

32 Engage plan members Consumerism Healthcare Consumerism The philosophy and practice of informing, rewarding, and engaging members to make prudent healthcare decisions, regardless of plan design Consumer-Directed Health Plans An approach for providing healthcare benefits that combines a high deductible health plan (HDHP) with a tax advantaged account (e.g., HRA or HSA). 32

33 Add financial incentives to motivate desired behaviors Align plan goals with financial incentives to the consumer - Plan design incentives generics and mail - Co-pay waiver programs - Rebate sharing - Higher level of coverage for preventive care Empower members to take more control of their health - Multi-channel member education - Health and wellness management programs - Rewards programs 33 Consumerism

34 Specialty Drugs Closely manage specialty drug utilization to protect costs and patient safety Provide affordable coverage to off-set plan costs Manage utilization and demand Align member choice with plan s intentions Permit coverage within the provisions of the plan Assure safe and effective use 34

35 Align healthcare investment Well Acute Chronic Total Healthcare Management Complex High-Risk Care Management Targets high risk and complex patients though one-on-one case management and coordination of care Population Disease Management Disease state management Engage individuals based on risk & acuity Integrated Disease Management & Wellness Risk management program that delivers financial rewards to participants based on quantifiable improvements in health status Detects at-risk populations before they become chronic and costly 35

36 Summary The pharmacy benefit is becoming more complex New challenges arising along with new opportunities to better control costs Today plan sponsors are focused on Increasing generics and mail utilization to drive savings Influencing members to focus on savings as well as their own personal health Balancing cost with care In the near future, plans will need to consider the impact of personalized medicine 36

37 Questions & Answers 37