Pharmacy Acquisition Cost and Its Role in Contract Negotiating

Transcription

1 Pharmacy Acquisition Cost and Its Role in Contract Negotiating Presented by: Todd Grover Glass Box Analytics August 23, 2017

2 Understanding Pharmacy Acquisition Cost (AC) Drives Relationship Pairs Pharmacy Distribution System 2

3 Industry Sources of AC Benchmarks o Government (Federal + State) National Average Drug Acquisition Cost (NADAC) - CMS Average Actual Acquisition Cost (AAC) seven states o Commercial Predictive Acquisition Cost (PAC) Does your source for an AC benchmark meet the following criteria? Transparency benchmark bears a genuine relationship to the actual acquisition cost of the drug. (In addition to this relevance definition, transparency also sometimes refers to being understandable.) Accessibility benchmark readily accessible and can be readily adopted by the pharmacy industry. Comprehensiveness benchmark available for all branded + generic drug groups. Timeliness benchmark updated with a frequency appropriate to the quickly changing actual acquisition costs, especially for generic (multi-source) products. Avoidance of Manipulation benchmark safe from manipulation. Criteria drawn from major industry initiatives in : National Council for Prescription Drug Programs workgroup on AWP replacement Academy of Managed Care Pharmacy position paper in Journal of Managed Care Pharmacy National Association of Medicaid Directors position paper 3

4 Use Cases Built on Understanding AC State Medicaids: Validate AACs Tune SMACs Employer / Plan Sponsor: PBM proposal evaluation and contract performance Operational Grade out PBMs, challenge/negotiation research Wholesaler RFP and contract pricing consistency U&C/cash pricing Loss File analysis Proxy for actual AC; alternative to submitting invoices MAC optimization + balance Identify opportunities to create savings for clients Improve GER predictability Justify pricing (PBM vs wholesaler) Meet state regulatory requirements for MAC transparency Defend pricing when challenged by payer/pbm + challenge aggressive payer/pbm MACs Proxy for actual acquisition cost; alternative to submitting invoices Understand market view of drug pricing after sale to wholesaler or pharmacy Insight into pricing across generic drug categories Price elasticity, forecasting 4

5 AC Benchmarks are Critical for Two Fundamental Drug Pricing Activities Establishing or assessing specific drug prices Measuring the overall quality of a price list 5

6 PBM Reimbursements 6

7 Typical PBM Contract Components Reimbursement Brand AWP less X% or U&C + dispensing fee (under days) AWP less X+% or U&C + smaller dispensing fee (over days) Generic AWP less Y% or MAC or U&C + dispensing fee (under days) AWP less Y+% or MAC or U&C + smaller dispensing fee (over days) Deductions POS charges, administrative charges, claim overpayments, reversals DIR fees catch all for fees that cannot be determined at POS Generic Effective Rate (GER) demanded by some larger pharmacy operators Measure overall generic reimbursement with a GER construct (i.e. the average percent discount off the AWP for all generic drugs) 7

8 PBM MAC Optimization Goals MAC optimization drives value in three key areas Balance Identify outliers warranting price adjustment Network Relations Increase MAC prices where overly aggressive Transparency Embed AC in overall pricing strategy that can be justified, balancing payer and provider issues For a given pharmacy profit target, the AC range in turn translates into a range within which the MAC should lie: Minimum Pharmacy per-script Profit Target AC low AC high MAC low MAC high 8

9 Pharmacy Pricing Activities and the Use of AC Benchmarks 9

10 AC Benchmarks and a Pharmacy s Pricing Activities Loss File Analysis Reimbursement Procurement PBM Grading AC low AC high U&C Price Setting Pricing Guarantees 10

11 Use of an AC Benchmark to Establish/Assess Specific Price U&C/Cash pricing Analysis of Loss File 11

12 Loss-file Analysis Identify if loss-file issues more likely due to PBM reimbursement versus procurement issues. For any specific claims, the Pharmacy can use an AC benchmark to identify which party it should direct its attention towards i. Identify claims where the PBM is paying less than AC-low ii. Identify claims where the Wholesaler/Manufacturer is charging more than AC-high AC low AC high 11

13 The DIR Challenge DIR Direct and Indirect Renumeration (CMS) Intended to address price concessions that would impact gross drug costs for Part D plans that are not captured at the POS DIR fees have become a catch all for PBMs Participate in a preferred network flat fee or percentage per claim Payment reconciliation true up to a target reimbursement rate Performance metrics refill rates, generic dispensing rates, preferred product rates, error rates, custom quality measures Started in Part D but similar fees incorporated into commercial networks How to manage DIR fees? Diligence and improved performance Interview with Valerie Fortin, Sr Director PBM Relations at AccessHealth - An acceptable MAC price TODAY may be unacceptable after DIR fees (weeks or even months later) conduct regular monthly and quarterly reviews of reimbursement performance across PBMs and plans 13

14 U&C Price Setting U&C Price Starting point often based on AWP k% or w% of Brand Challenges include: Disconnect between AWP / WAC and AC Reacting to acquisition cost changes, and other market dynamics, given how static AWP tends to be An AC benchmark based starting point is more prudent Begin at a competitive, but profitable, level Quickly identify when acquisition-cost price changes warrant an adjustment 12

15 U&C Price Setting Measure impact on insured business, relative to impact on uninsured. Monitor published U&C of most relevant competitors, for most active drugs Use an AC benchmark to set starting point for U&C. Adjustments can then be made per the other considerations. U&C Price NDC Drug Name Qty # Claims Current U&C AC U&C CITALOPRAM HBR 20 MG TABLET $ 6.32 $ FINASTERIDE 5 MG TABLET $ 8.34 $ FLUOXETINE HCL 40 MG CAPSULE $ 8.44 $ NAPROXEN 500 MG TABLET $ 6.11 $ CITALOPRAM HBR 40 MG TABLET $ 5.98 $ CEPHALEXIN 500 MG CAPSULE $ 7.99 $ CITALOPRAM HBR 10 MG TABLET $ 6.64 $ BENAZEPRIL HCL 40 MG TABLET $ 7.67 $ BENAZEPRIL HCL 20 MG TABLET $ 7.97 $ ALPRAZOLAM 0.5 MG TABLET $ $ CLONIDINE HCL 0.3 MG TABLET $ $ HYDROCORTISONE 2.5% CREAM $ 6.67 $ NYSTATIN-TRIAMCINOLONE CREAM $ $ VIT D MG (50,000 UNIT) $ $ ALBUTEROL 0.083% INHAL SOLN $ 7.80 $ Should be taken care of via AC-based starting point for price. Incorporate actual acquisition-cost to set floor ALPRAZOLAM 0.25 MG TABLET $ $ NAPROXEN 375 MG TABLET $ 7.31 $ 8.05

16 Use of an AC Benchmark to Measure the Overall Quality of a Price List Grade out PBMs Wholesaler RFP and Pricing guarantees 16

17 Background: Price List Quality Generic Effective Rate (GER) Generic Effective Rate (GER) Generic Effective Rate (GER) is an effective measurement of a price list s performance if using an underlying reference that tracks acquisition cost The charts correspond to pricing that delivers a 74% GER when measured across all claims AWP-based AC-based 17

18 Background: Price List Quality Key Challenges with AWP-based GER Key Issues Stability / Relevance Predictability Because AWP is so disconnected from pricing, a movement in GER may not reflect a movement in price GER: ~68% for Acute meds, ~%85 for Maintenance Meds GER depends on which generic manufacturers a pharmacy purchases from, adding a degree of uncertainty in GER Group Drug Label MAC NDC AWP GER TRETINOIN 0.05% CREAM % TRETINOIN 0.05% CREAM % Interpretability While PAC moves with Acquisition Cost, AWP is often static even when the underlying drug price is changing, impacting relationship between GER and profitability 18

19 Grading Out PBMs Plan by Plan AC benchmarks serve as better reference points than AWP for benchmarking the quality of a price list Compare each PBM s reimbursement using a common, independent acquisition cost measurement Difficult to use AWP because resulting GER is so sensitive to drug mix, and even to manufacturer from whom drug is purchased Can use AC benchmarks rather than AWP as the MSRP off of which to measure GER; compare plan by plan GER (AWP) GER (AC) 19

20 Wholesaler RFP / Pricing Guarantees Assessing a wholesaler s prices using a GER based on an AC benchmark can be done in a very similar manner to that illustrated for grading out PBMs Example: Compare wholesalers during RFP by using an AC based GER Example: Contractually require a wholesaler to deliver a majority of drugs at specified AC-based GER 19

21 Q&A 21