Transcript Office of Workers' Compensation Program

Fighting Rising Prescription Costs in the
Workers’ Comp Environment
Celeste Player, PharmD
Clinical Account Executive
Express Scripts
June 3, 2008
Joe
…at home
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Joe
…at work
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Work-related accidents are decreasing…
2
1.5
Total Claim
Counts per
100 Workers
1.5
1
1.1
0.5
0
2000
2006
Source: N.C.C.I.
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…but medical costs are increasing
2006
2000
Total Spend: $68.6 B
Medical Spend: $40 B
Total Spend: $47.6 B
Medical Spend: $20 B
44%
41%
56%
59%
Medical
Indemnity
Source: National Academy of Social Insurance; Health Strategy Associates
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Pharmacy is a key contributor
Pharmacy as a Percent of Medical Spend
16%
14%
Drug:Medical
Ratio
12%
10%
'98
'99
'00
'01
'02
'03 '04E '05E '06 '07E '08E '09E
Pharmacy % of Medical Spend; E designates
estimated value
Source: N.C.C.I.; Health Strategy Associates
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Challenges within a Unique Market
Threat of legal
involvement
Absence of
copays
State regulations
Workers’
Compensation
Third Party
Billers
Limited clinical
programs
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Contributors to increasing pharmacy costs
Annual Pharma Spending on Direct-to-Consumer (DTC) Ads
Pharma DTC Ads:
$4.2 Billion in 2005
$
Billions
$2.8
$3.0
$2.9
2000
2001
2002
$4.2
$4.2
2004
2005
$3.5
$2.2
$1.0
1996
$1.3
1997
$1.6
1998
1999
2003
Source: Donohue JM. N Engl J Med 2007;357:673-81.
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Four of the Top Six WC Drugs Are DTC Targets
®
*OxyContin®
Duragesic®
*Actiq
*Lyrica®
Lidoderm®
*Celebrex®
* Indicates DTC target
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Brand vs. Generic Cost Comparison
Workers’ Compensation
$200
$214.08
Average Cost per Rx
$197.10
$176.22
$150
$155.26
$138.00
Brand Drug
$100
Generic Drug
$50
$34.92
$37.45
2003
2004
$50.76
$55.32
$57.50
2005
2006
2007
$0
Source: Express Scripts national statistics
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Source: ESI national Work Comp statistics
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Mix Matters
Net Cost
= Channel
where?
Use
Mix
how many Rxs? which drugs?
WASTE = extra $ spent with no additional health gained
Same drug,
higher price
Drugs used,
but not needed
More expensive,
but not more effective
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Product Offering
CORE
TREND
CLINICAL
Basic PBM offerings customized
to meet your specific goals
Focus on mix and
distribution channel
Focus on safety






Drug List
Includes
Includes
Drug Exception Process
 Home Delivery Education
 Physician Outreach Program
 Step Therapy
 Retro DUR
 Predictive modeling
 Independent Pharmacist
Network strategy
Home Delivery
Review
First Fill
Paper Bill Process
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Drug List Management:
CORE OFFERING
Workers’ Comp Drug List
 Appropriateness to injury
 Therapy guidelines
 Limits by date of injury, cost and fills
 Customized to meet client needs
 Ability to include/exclude drugs, physicians at
program or patient level
 Supported by clinical pharmacists
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Focusing Our Efforts
TREND
TRENDOFFERING
OFFERING
Continuous need to reduce use of single-source brands (SSBs) and
multi-source brands (MSBs) and increase generics
 Step Therapy
 Physician Outreach  Generic mandates
 Physician education Program
 Step Therapy
 Physician Outreach
Program
SSBs
MSBs
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Generics
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Physician Outreach Program
TREND
TRENDOFFERING
OFFERING
 What is Physician Outreach Program (POP)
 Communications aimed at encouraging the use of generics when
appropriate
 Promotes the use of clinically appropriate, cost-effective therapy
 What drugs are currently being targeted
All multi-source brands prescribed as DAW1
 What is the goal of the program
To reduce the number of multi-source
brands and increase the number of
generics being dispensed
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Step Therapy
TREND OFFERING
Trend management tool addressing rising drug costs
 Encourages lower cost (typically generic) therapies
 Edits applied at point of service limit impact to patients
 Reduces prior authorization call volume and administrative costs
 Primary classes include SSRI, COX-2, and PPI
If history is present,
claim pays
PBM
PBMPBMPBMPBM
PBM
PBMPBMPBMPBMPBM
PBM
PBMPBMPBMPBMPBM
System checks
PBM
PBMPBMPBMPBMPBMPBM
for history ofPBM
PBMPBMPBMPBMPBM
PBMPBMPBMPBMPBM
PBM
step
1 drug(s)
PBMPBMPBMPBMPBMPBM
PBMPBMPBMPBMPBMPBM
PBMPBMPBMPBMPBMPBM
Rx written
R.Ph
PBM
Prior authorization required; Call MD; Must try step 1 drug first
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If no history,,
claim rejects
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Home Delivery
TREND OFFERING
 Additional savings beyond network rate
 Convenience for injured workers
$234.22
 Drug utilization review (DUR) integrated with retail
for
consistency
 Home Delivery conversion capability
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Predictive Modeling Program
CLINICAL
CLINICALOFFERING
OFFERING
 Report designed to forecast potential for risk in workers’
compensation environment
 Identifies claims that represent potentially inappropriate
patterns of drug utilization
 Assists in evaluating the need for interventions:
 Case management
 Independent medical examinations
 Physician, peer-to-peer conversations
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Retrospective DUR
CLINICAL
CLINICALOFFERING
OFFERING
Letters sent to physicians
Changing patient’s drug regimen achieves savings
Substance abuse,
addictive
substances
Duplicate therapy
Long-term
hypnotics
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 SSRIs
 NSAIDs and COX-2
inhibitors
 PPIs and H2 blockers
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2007 Drug Trend Results
All metrics trending in the right direction
Express Scripts
Trend
2006
2007
Network Penetration
84.7%
87.7%

Network penetration
improved 3.0%
Generic Fill Rate
66.3%
68.4%

GFR increased 2.0%
from 2006 to 2007
Overall Drug Trend
11.4%
6.0%

Overall drug trend
declined by 5.4%
Source: Express Scripts national statistics
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How Do We Bend the Trend?
 Know the landscape
 Recognize that prescription costs CAN and MUST be
managed in workers’ compensation
 Utilize the proven tools at your fingertips
 Partner for better outcomes
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Questions?
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