Transcript Why Don`t Your Patients Take Their Medications and What Can You

Challenges and Opportunities for
Pharmacy Directors
a.k.a.
What Keeps Us Awake at Night
Michigan Association of Health Plans
Summer Conference
Carrie Germain, R.Ph.
HealthPlus of Michigan
Senior Director, Pharmacy Services
Chair, MAHP Pharmacy Directors Committee
July 15, 2015
Objectives
• Specialty Medications
• Rising Cost of Drugs
• Legislative Initiatives
• Focus on Quality
• Transitions of Care
Specialty Medications
• Balancing value and potential for clinical improvement
against the cost of specialty medications
• Annual impact on prescription expenses
• Specialty Medications=1% of claims and 28-30% of
expense
• Hepatitis C treatments=>9% of expense
• Annual specialty drug trend is 18%-22%
• Top specialty categories:
• Autoimmune, Cancers, Multiple Sclerosis, Hepatitis C, HIV
Specialty Medications
• 50% of drug pipeline consists of specialty and biologics
• By 2018, 50% of prescription expense projected to be
specialty meds
• By 2020, 50% of the top 50 selling Rx products will be
specialty meds
• Impact on government programs (Medicare, Medicaid,
Exchanges)
• Within 10 years, 10 breakthrough drugs predicted to
cost $50 billion
Specialty Medications
• Plans work with specialty pharmacies to implement
clinical criteria/protocols; quantity or days supply
limits to control waste; lab and efficacy monitoring;
medication adherence support
• Medical injectables/infusions are increasingly
managed by pharmacy management staff
• Prior authorizations and site of service optimization
can result in savings, convenience and better
outcomes (e.g., IVIg, Remicade)
Specialty Medications
• On the immediate horizon:
• PCSK9 Inhibitors
• proprotein convertase subtilisin/kexin type 9 inhibitor
• Monoclonal antibody
• Sub Q every 2-4 weeks
• Cholesterol lowering agent may be approved for:
• Familial Hypercholesterolemia
• Intolerance to statins
• Possibly as traditional therapy
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LDL lowering-could be as high as 60%
Praluent-July 24th and Repatha-August 27th
$7000-$12000 per year
Future annual US costs estimated at $50B-$200B
Rising Cost of Drugs
• Generics Prices
• Impact of manufacturer consolidation and product line
downsizing:
• 1000’s of percent increase in 2014
• Tetracycline-7,000%-17,000%
• 100’s of percent increase in 2015
• Propranolol- 300%-400%
• Brand Prices
• Multiple increases per year
• e.g., Insulin increased 27% in 2014
• At what point does drug affordability impact treatment
adherence and have negative consequences on total
healthcare costs?
Legislative Initiatives
• Biosimilars
• Biosimilars=highly similar lower cost versions of innovator
products (Follow on Biologics or FOBs)
• Interchangeable biologics=biosimilars that meet
additional standards for interchangeability
• Estimated savings for biosimilars/interchangeable
biosimilars, 10-30%
• Bills have been passed in 15 states and are pending in
four states, including Michigan
• Allows pharmacist to substitute an interchangeable
biosimilar and notify patient of the substitution.
Substitution of biosimilars would require notice to the
prescriber before dispensing.
Legislative Initiatives
• Pharmaceutical Cost Transparency
• Requires manufacturers to report costs such as:
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Research and development
Purchase of drug patent/drug company,
Clinical trials and regulatory costs
Profits
All marketing costs for higher cost drugs on an annual
basis.
• Similar legislation has been introduced in other
states (e.g., MA, PA, NY, NC, CA)
• This is an opportunity to raise public and legislator
awareness for the challenges to healthcare related
to very high cost products
Legislative Initiatives
• Maximum Allowable Cost
• Passed in 2014; Implemented April 1, 2015
• Plans required to publish process for generic
drug MAC pricing questions and
reconsideration within defined timeframes
• Must provide up to 3 NDCs for manufacturers
within the price range from wholesalers who
deliver in Michigan
Legislative Initiatives
• Medication Synchronization
• Legislation pending and under comment by MAHP Pharmacy
Directors
• Heavily supported by pharmacy providers
• Requires health plans to allow synchronization of medication
regimens without reduction in dispensing fees
• MAHP advocating for prior approval by plan for clinical reasons
• Auto Refill
• MAHP Pharmacy Directors support introduction of legislation that
requires patient involvement/permission for auto prescription refill
programs for each drug, each time.
• Goals of this legislation is to reduce waste and avoid instances
where someone picks up a prescription for someone and patient
doesn’t need the drugs.(e.g., Insulin, drugs that have been
discontinued)
Legislative Initiatives
• Audit Bill
• Any Willing Provider
• Pharmacy Benefit Management Legislation
Quality Focus
• HEDIS and Medicare Stars
• Right Drug, Right Time for the Right Person
• Focus has been on engaging physicians and members
• Opportunities exists to further integrate pharmacy
providers in these efforts
• Community pharmacists are increasingly aware of the
importance of their Star ratings and the impact on
network inclusion and in the future, possibly
reimbursement
• Work with pharmacists to:
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Address adherence issues
identify therapy gaps
Simplify regimens
Reduce medication costs
Synchronize refills
Transitions of Care
• Focus on high risk chronic conditions
• CHF, MI, AF, Asthma/COPD, Pulmonary Embolism,
Diabetes, etc.,
• Reduce likelihood of readmission and improve
outcomes
• 30% of readmissions within one year are due to
an adverse drug event
• 70% of patients who were hospitalized have at
least one actual or potential medication
discrepancy at discharge
• How do we improve these statistics?
Transitions of Care
• All stakeholders need consistent and timely access to
electronic data
• Hospital staff-obtain and record accurate medication
reconciliation upon admission
• Inpatient pharmacy staff
• Physicians (PCP and Specialists)
• Health Plan Pharmacist
• Community and Specialty Pharmacy Pharmacists
• Home Care, Home Infusion and DME providers
• Ensure reliable handoffs, accurate and timely
documentation and follow up to monitor
recommended therapy adherence
Transitions of Care
• All stakeholders need consistent and timely access to
electronic data
• Hospital staff-obtain and record accurate medication
reconciliation upon admission
• Inpatient pharmacy staff
• Physicians (PCP and Specialists)
• Health Plan Pharmacist
• Community and Specialty Pharmacy Pharmacists
• Home Care, Home Infusion and DME providers
• Ensure reliable handoffs, accurate and timely
documentation and follow up to monitor
recommended therapy adherence
Questions?
Carrie Germain, R.Ph.
[email protected]
810-230-2299