Understanding PBM Quality The 2 nd National Alliance PBM Report John Miller john.miller@mabgh.org 1
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MARKET SHARE All Other 3% MedImpact 5% Prime Therapeutics 6% CVS/Caremark 25% Humana 7% Envision Rx 1% Optum Rx 23% Express Scripts 30% Source: Deutsche Bank Markets Research; George Hill, PBMI Annual Meeting, March 2017 3
4 What is the PBM Assessment? What it is NOT: A Pricing Tool What it IS: a Quality Assessment Tool Evidence-Based Questions from PBM module of health plan assessment, with additional questions from consultation with external consultants Provides guidance to what Employers can and should expect from their PBM Provides a common comparison across Carve-in and Carve-out, Large and Small, and Transparent and Traditional PBMs 4
5 This Assessment is best used as a conversation guide. We have included discussion questions along with the Assessment results. Use not only the results, but the discussion questions in your meetings, both with your existing PBM, and with prospective PBMs. INSIST THAT YOUR PBM, AND ANY PBMS YOU CONSIDER, PARTICIPATE IN THE PBM ASSESSMENT! 5
6 Summary of Results Specific areas as opportunities for improvement across all/most of the respondents: 1. Reducing overuse of antibiotics of concern 2. Working with pharmacy network to track and act on primary non-fulfillment (when first prescription is not filled) 3. Coverage polices and recommendations for substance use medications 4. Improving adherence rates for key medications for diabetes and high cholesterol 5. Appropriate treatment of cholesterol in members with heart disease 6. Ensuring optimal treatment of members with asthma 6
7 Overall Performance 100.00% 90.00% 80.00% 70.00% 60.00% 58.1% 64.5% 62.1% 72.5% 80.5% 50.00% 43.8% 49.0% 49.8% 40.00% 36.10% 30.00% 20.00% 10.00% 0.00% A B C D E F G H I 7
Pharmaceutical Management UNDERSTANDING PBM QUALITY WEBINAR YEAR 2 8
9 Pharmaceutical Management 100.00% 90.00% 80.00% 76.6% 70.00% 60.00% 60.9% 56.9% 63.7% 61.5% 50.00% 40.00% 42.1% 44.7% 46.1% 30.00% 29.10% 20.00% 10.00% 0.00% A B C D E F G H I 9
10 Pharmaceutical Management A B C D E F G H I Program Organization Formulary Customization Rebates Practices Efficiency & Appropriateness: Generic & Appropriate Drug Use Management Strategies Generic Dispensing Rate Specialty Pharmaceuticals Management Strategies Benefit Design Options Site of Care Adherence Programs Quality, Safety and Adherence: Outpatient Appropriate Medications Safeguards Adherence Reminders Drug Conflicts Opioid Management Assessment of Pharmacies in network Pharmaceutical Support - CAD, Diabetes, BH Monitoring Adherence and Closing Gaps Adherence Results Coverage Monitoring appropriateness of antidepressant prescribing practices of practitioners. Pharmaceutical Support - Tobacco and Obesity Coverage Eligibility Criteria for Obesity 46.7% 33.3% 46.7% 46.7% 46.7% 46.7% 46.7% 73.3% 100.0% 56.6% 19.2% 51.3% 34.5% 62.0% 41.4% 75.2% 52.0% 66.6% 87.6% 58.5% 72.2% 61.6% 98.8% 79.9% 81.8% 92.1% 97.4% 22.0% 28.8% 19.5% 48.4% 7.3% 39.8% 33.4% 53.2% 71.2% 73.1% 12.3% 25.5% 45.4% 29.6% 67.8% 72.2% 56.8% 78.1% 33.3% 70.5% 45.5% 22.7% 0.0% 37.9% 7.6% 40.9% 42.4% 10
11 Program Organization I H G F E D C B A 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% This section assesses the PBMs ability to provide a Value-Based Formulary, the PBMs rebate practices, and the PBMs flexibility. Scoring differences are based on: The option of a value-based formulary that is based on evidence and not based on contracts with manufacturers The ability to provide an example of a value-based benefit design with at least one Employer Flexibility in allowing Employers to customize certain functions 11
12 Discussion Point: If you want to exercise more power over your own formulary decisions, how much leeway does the PBM allow? What areas would they see as candidates for change? 12
13 Efficiency & Appropriateness: Generic & Appropriate Drug Use I H G F E D C B A 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% This section assesses the breadth and types of strategies PBMs use to assure appropriate, cost-effective utilization. All respondents utilize a broad range of strategies (e.g., therapeutic interchange, step therapy, mandatory mail order refills) Scoring Differences were based on: Generic dispensing rate Addressing overuse of antibiotics of concern Programs in place to assure stabilization of medication regimens prior to filling drugs via mail service or extended retail 13
14 Discussion Points With the current concerns regarding antibiotic resistance, what steps is the PBM taking to assure appropriate prescribing? How does your PBM s (and your company's) generic dispensing rate measure up to industry benchmarks? What steps can you take to save money in this area while still protecting your employee's health? Is the PBM making sure that medication is appropriate and well-tolerated before moving to mail-order? 14
15 Specialty Pharmaceutical Management I H G F E D C B A 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% This section looks at administration (medical or pharmacy benefit), utilization strategies, such as Prior Authorization and Step Edits, Channel Management (limiting dispensing to specific providers), and patient adherence for these very expensive drugs. All PBMs have broad range of programs to manage specialty pharmaceuticals, and can provide example and results of program implemented to reduce waste/inappropriate use. Scoring Differences were based on: Programs and processes in place to manage members and monitor for gaps in adherence. The PBM s willingness to provide Per Member Per Month costs for listed conditions 15
16 Practices related to Specialty Rx Management A B C D E F G H I Split Fill Genomic Testing Channel Management Site of Care Optimization Reimbursement based on a fixed fee schedule Use of NDC Code by Physicians for SPs Optional No Optional Req No Req Optional Req for 3 agents 16
17 Discussion Points Given the sizable expense for each dose, and the waste if medications are not taken as directed, how is the PBM ensuring that your investment is achieving the intended health outcome? Many specialty drugs are significantly more expensive in the hospital setting: is the PBM monitoring the site of care and working with other vendors to make sure the drugs are administered in the highest value setting? How do they measure and demonstrate results? PBMS use different numerators in calculating PMPM for specialty drug classes have your PBM define their numerators and denominators when providing information to you 17
18 I H G F E D C B A Outpatient Quality, Safety and Adherence 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% This section examines the PBMs programs to monitor and manage patients on long-term medications. It also looks at how the PBM tracks and manages drug conflicts, and potential Opioid misuse. Scoring Differences were based on: Ability to address drug-drug conflicts and opioid misuse Performance and Reporting on optimal control of members with asthma. Quality of monitoring members on asthma, and COPD Assessment of network pharmacies 18
19 Discussion Points Opioid (pain medication) misuse is a growing concern for employers. How is the PBM monitoring and managing this issue? Is the PBM effectively monitoring for proper adherence for asthma and COPD medications? Does the PBM conduct some sort of safety and quality survey of its retail pharmacies? 19
20 Rx Management in Chronic Condition Management I H G F E D C B A 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% This section examines the PBMs ability to support patients with Chronic Disease or Behavioral Health issues, including adherence monitoring and coverage of BH/substance use medications Scoring Differences were based on: Appropriate treatment of cholesterol in patients with heart disease Adherence monitoring (diabetes, CAD, depression and substance use) practices and rates Monitoring appropriateness of antidepressant prescribing practices of practitioners. Coverage of and access to medications to treat substance use 20
21 Discussion points Note that adherence is measured by having the drug available, and that respondents with automatic refill programs will have higher rates of adherence than those who do not automatically send out refills. Automatic refill programs may also lead to waste. How does your PBM look at this question? What is the PBM's position on substance use medication; do they recommend coverage, and monitor adherence? Why or why not? 21
22 Rx Management for Tobacco Cessation and Weight Management I H G F E D C B A 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% This section measures how the PBM supports Rx coverage of Obesity and Tobacco medications Scoring Differences in this section were based on: Options to reduce barriers for medications to treat tobacco cessation and for weight management medications. Whether PBM provided guidance on eligibility criteria for covering medications for weight loss Whether the PBM advises clients that all tobacco cessation medications need to be covered with no OOP for members 22
23 Discussion Points Tobacco use and obesity are major contributors to many companies' overall expense. What coverage policies does the PBM recommend regarding medications to treat these expense drivers? Why do they take this position? 23
Member Engagement UNDERSTANDING PBM QUALITY WEBINAR YEAR 2 24
25 Member Engagement 100.00% 90.00% 80.00% 84.7% 90.9% 70.00% 68.0% 60.00% 50.00% 46.8% 40.00% 38.5% 38.2% 40.0% 39.4% 30.00% 28.4% 20.00% 10.00% 0.00% A B C D E F G H I 25
26 Member Engagement A B C D E F G H I Racial, Cultural and Language Competencyy Member Demographics & Sources of Information 0.0% 52.4% 11.2% 77.2% 19.4% 46.9% 27.5% 89.8% 86.7% Provider Demographics Using the Information Health Literacy Alignment of Benefit Design/Incentives Reducing Barriers for Chronic Disease 50.0% 0.0% 100.0% 0.0% 100.0% 89.3% 0.0% 75.9% 100.0% Reducing Barriers for Acute Care Price Transparency and Member Experience Cost Calculators 66.7% 56.7% 43.3% 45.0% 43.3% 63.3% 50.0% 85.0% 100.0% Patient-Centered Care/Care Coordination Member Support & Programs- Cardiovascular Disease, Diabetes, 63.0% 11.6% 31.3% 35.0% 32.7% 84.7% 93.2% 93.6% 93.2% Behavioral Health Member Support & Programs, Tobacco and Obesity 10.2% 54.5% 24.9% 0.0% 0.0% 0.0% 2.9% 37.3% 61.0% 26
27 Racial, Cultural and Language Competency I H G F E D C B A 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% This section measures how well the PBM supports and engages members with who are racially/ethnically/culturally diverse and may have limited language and health literacy Scoring Differences in this section were based on: Capturing demographic information on new and existing members and using information to support member s language and/or cultural needs as well as supporting those with health literacy limitations Evaluation of the impact of language and/or literacy activities 27
28 Consumer Engagement Overview Member Demographics: Few PBMs know their members ages, race/ethnicity or primary languages spoken Cost Calculators Most PBMs provide medication costs searchable by drug, with the cost information related to the members specific benefit design. Some PBMs included additional features such as comparing drugs, e.g. therapeutic alternatives Most of the carve-out respondents did not assess the use or impact of the cost calculator. For the respondent that did assess use, percent of unique users was very low (less than 5% of members); highest was 15% 28
29 Discussion Points Without information on age, race, ethnicity, and languages spoken, how does the PBM tailor its adherence and drug choice messages to members? How does it monitor proper dosing for members of different races/ethnicities? How is the PBM engaging members in making cost-effective decisions regarding medications, and empowering them to make wise decisions? Does the PBM measure the impact of their efforts, to demonstrate effectiveness? 29
Business Practices UNDERSTANDING PBM QUALITY WEBINAR YEAR 2 30
31 Business Practices 100.00% 95.70% 94.0% 95.3% 93.2% 95.1% 95.1% 90.00% 80.00% 70.00% 67.5% 72.4% 60.00% 58.30% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% A B C D E F G H I 31
32 Business Practice A B C D E F G H I Third Party Accreditations (URAC) Level of access for third-party audit E-Prescribing 98.6% 90.0% 66.0% 95.8% 100.0% 97.2% 97.2% 95.8% 66.3% Client Support: Data Analyses and Reporting; Beneficiary Communication and Outreach support; Co-ordination and Collaboration Employer Reporting: Type, Frequency Beneficiary Communication and Outreach Performance Guarantees Specialty Drug Reporting 86.0% 92,1% 72.7% 87.9% 79.3% 79.7% 87.9% 92.9% 92.9% 32
33 DON T SEE YOUR PBM IN OUR REPORT? WORK WITH YOUR CONSULTANT OR BROKER TO INCLUDE THIS LANGUAGE IN YOUR NEXT REQUEST FOR PROPOSAL AND CONTRACT! My company expects PBMs to participate in all National Alliance of Healthcare Purchaser Coalitions sponsored PBM Assessment surveys and activities. PBMs will annually supply most recent scores in the following categories: A. Plan participated, scores follow: Business Practices Pharmaceutical Management Services and Results Activities/Tools and Services to Engage Members B. Plan did not participate. 33
Participating PBMs PBM 2014 2016 2017 CVS Health Cigna Carve-In Envision Rx Express Scripts Magellan Rx Perform Rx UHC Carve-In Optum Maxor BeneCard 34
35 Some of the NON-Participating PBMs AmWins Rx Pharmacy Benefit Dimensions Argus Pharmacy Data Management, Inc. Humana Pharmacy Solutions BeneCard PBF PharmAvail Benefit Management MaxorPlus, Ltd. Capture Rx Phoenix Benefits Management MedImpact Healthcare Systems, Inc. Citizens Rx PMSI Meridian Rx, LLC ClearScript Progressive Medical Inc. Navitus Health Solutions LLC Emdeon Ramsell Corporation Prime Therapeutics Employee Health Insurance Management, Inc. RegenceRx US Script, Inc. Healthesystems LLC Restat L.L.C. WellDyneRx Integrated Prescription Management ScriptSave Abarca Health Kroger Prescription Plans MedTrak Services Serve You Custom Prescription Management Total Script Pharmpix Corporation mymatrixx VRx Pharmacy Services ProCare Rx PBM Partners Rx MC-21 Corporation 4D Pharmacy Management Systems Inc. PBARx, LLC Aetna Life Insurance Company American Health Care PBM Plus, Inc. FutureScripts, LLC Pharmaceutical Technologies, Inc. 35
36 A Final Reminder All of the information in this webinar is included in the National Alliance 2016 PBM Assessment; Understanding PBM Quality Use the report in preparing for meetings with your PBM, and require your PBM to participate in the National Alliance PBM Assessment INSIST THAT YOUR PBM, OR PROSPECTIVE PBMS, PARTICIPATE IN THE ASSESSMENT! 36
37 Thank you! 37