Transcript Innovative Pharmaceutical Programs and the Future of Pharmacy

Innovative Pharmaceutical Programs and the
Future of Pharmacy Benefits
Daniel Opinante
President Seneca Consulting
• Reclassification of “Single-Source”
generics as “Brand” medications
• “Generic First” program
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Generic Pipeline (short)
GPI
Drug Name
56852070107020
49270070102120
39400010100310
39400010100320
39400010100330
39400010100350
44209902706320
44209902706330
44209902706340
44505050100330
44209902706320
40304070100310
58160034100320
39400060100305
44505050100330
FLOMAX
CAP0.4MG
PROTONIX INJ40MG
LIPITOR TAB10MG
LIPITOR TAB20MG
LIPITOR TAB40MG
LIPITOR TAB80MG
ADVAIR 100/50 DISKUS
ADVAIR 250/50 DISKUS
ADVAIR 500/50 DISKUS
SINGULAIR 10 MG TABLET
ADVAIR 100/50 DISKUS
VIAGRA 25 MG TABLET
LEXAPRO 10 MG TABLET
CRESTOR 5 MG TABLET
SINGULAIR 10 MG TABLET
Launch Date
05/01/2010
01/08/2011
11/01/2011
11/01/2011
11/01/2011
11/01/2011
08/01/2011
08/01/2011
08/01/2011
08/31/2012
08/01/2011
03/31/2012
03/31/2012
06/30/2012
08/31/2012
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Drug Reclassification
• The cost difference between “new” generic and brand is
slight.
• New generics may only be available from a “Single
Source” manufacturer, or limited manufactures.
• On November 1, 2007, FDB announced that, they would
no longer publish Generic Price Indicator (GPI)
• GPI was the data element that classified what drug was
a generic, and what drug was a brand
• With out the GPI, the PBM determines what drug is a
brand, and what is a generic
• “Single Source” generics can have large effect on PBM 6
Drug Reclassification
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Effective Discount
-15%
-15%
-14%
-15%
-14%
-15%
-13%
-14%
-15%
-15%
-14.5%
Generic
Generic
Generic
SS Generic
Generic
Generic
Generic
Generic
Generic
Generic
Effective Discount
-50%
-50%
-50%
-20%
-50%
-50%
-50%
-50%
-50%
-50%
-47%7
Drug Reclassification
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
Brand
SS Generic
Brand
Effective Discount
-15%
-15%
-14%
-15%
-14%
-15%
-13%
-14%
-15%
-20%
-15%
-15%
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Effective Discount
-50%
-50%
-50%
-50%
-50%
-50%
-50%
-50%
-50%
-50%
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Drug Reclassification
The affect of single source generics being reclassified as
“Brand” medications with regards to “Brand” Discount
Guarantees.
• Brand Discounts: increased as much as 1.6%
• Generic Discount: increased as much as 5%
. “For purposes of the discount guarantees, our offer does
assume single source generics are reconciled to the brand
discount guarantee.”
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“Generic First Program”
• There are many single source and multi
source brand medications that do not have
a generic.
• Most of the single source and multi source
brand medications, are within a
therapeutic class that generics are
available
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“Generic First Program”
Class
Condition
Ace Inhibitors
HMG-CoA
Reductase Inhib
“Statins”
Proton Pump
Inhibitors
High Blood Pressure
High Cholesterol
Stomach Acid
Type
“Brand”
“Generic”
“Brand”
“Generic”
“Brand”
“Generic”
Ave $ per
script*
$110.00
$15.52
$150.00
$39.75
$229.60
$81.60
Ave
Savings*
%
$94.48
$110.25
$148.00
85%
73%
64%
*Blend of retail and mail service, prior to copay
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“Generic First Program”
Class
Condition
Selective Serotonin
Selective Serotonin
(SSRIs)
Hypnotics
Migraine
Depression
Insomnia/ Sleep
Type
“Brand”
“Generic”
“Brand”
“Generic”
“Brand”
“Generic”
Ave $ per
script*
$188.24
$124.70
$110.18
$25.69
$165.79
$36.48
Ave
Savings*
%
$63.54
$84.49
$129.31
34%
77%
78%
*Blend of retail and mail service, prior to copay
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“Generic First Program”
• Implement a step-therapy program.
Member must try the preferred generic
within therapeutic class. ($0 copay)
• If generic fails, member can step up to
preferred brand medication
• PBM rebate guarantees will be effected
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Sheila MacFayden
Chairperson, SSEHP
• Specialty Drug program
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Suffolk School Employees
Health Plan (SSEHP)
• K-12 School District Consortium
• Provides benefits to 11,000 participants
• Self-Insured
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What is a specialty drug?
Members using specialty drugs suffer from
complex, rare and life debilitating diseases.
What are Specialty drugs?
Injection, infusion or oral form, which may be taken
at home or given in a clinic or hospital setting
How much do specialty medications cost?
$1,300 average per Rx cost ($4,000 per oncology Rx)1
What additional care is required?
Members often need intensive, ongoing care
coordination, support and intervention
Which benefit covers specialty drugs?
Can be either the pharmacy or medical benefit
Specialty Diseases
Anemia
Asthma
Cystic Fibrosis
Endocrine
Enzyme Deficiency
Growth Hormone Deficiency
Hemophilia
Hepatitis B
Hepatitis C
HIV/AIDS
Immune Globulin
Immune Modulator
Infertility
Iron Overload
Multiple Sclerosis
Neutropenia
Oncology
Osteoarthritis
Parkinson’s Disease
Pulmonary Arterial Hyper.
Respiratory Synctial Virus
Rheumatoid Arthritis
Transplant
Tsunami Effect
5%
4%
Population %
Spec Drug Spend %
60%
4%
75%
60%
3%
45%
2%
30%
1%
0%
10%
1%
2004
Source: Managed Care Magazine,
15%
2010
0%
Significant Savings: Move to the Pharmacy Benefit
Pharmacy Benefit
Rheumatoid Arthritis
Cystic Fibrosis
Hepatitis C
Psoriasis
Crohn’s
Transplant
Growth Hormone
Multiple Sclerosis
Medical Benefit
Oncology
RSV
Infertility
Oncology Adjunct
Gaucher’s
HIV/AIDS
IVIG
Hemophilia
Move all specialty drugs to the pharmacy benefit
10% of the drug spend in a health plan is for specialty drugs
Benefits of Using a
Specialty Pharmacy Provider
Specialty
•
•
•
•
•
•
On-going drug management
Coordination with physicians
Monitoring compliance
Continual member outreach
Managing side effects
Helping members live with
disease
Retail
•
•
•
•
•
•
Minimal patient communications or
monitoring
Limited training in disease states
Traditional retail store hours
No proactive management
Limited access to nurse clinicians,
social workers, case managers
Facilities tailored to oral product
distribution
Better specialty care reduces total health care costs
Specialty Pharmacy Clinical Management
Our integrated Specialty management focuses on total cost reduction and better patient support.
Increased pharmacy costs – due to improved adherence – are significantly outweighed by medical
savings.
HepC
RA
Anemia
Neutropenia
$780
Transplant
Network Conversion Savings per Member
$1,269
$289
Adherence Improvements
Avg Medical Savings
Avg Specialty Rx Savings
Avg “Other” Rx Savings
17%
$3,780
($3,196)
$1,656
16%
$1,159
($791)
$503
Total Disease/Clinical Mgmt Program
$2,240
$871
Wastage & Notification Savings
$1,568
$4,014
$1,212
$4,380
$348
Total 1st Year Savings Per Member
$5,077
$5,174
$1,576
$18,386
($882)
32%
$3,382
($2,193)
($1,605)
($416)
$1,521
MS
$172
$929
53%
$15,804
($1,793)
($1,526)
19%
$891
($2,447)
$154
28%
$12,644
($765)
($510)
$12,484
($1,402)
$11,369
TBD
$12,298
HIV
Oncology
$370
15%
$1,257
($2,512)
$332
$1,763
50%
$22,928
($11,942)
($80)
($923)
$10,906
TBD
$6,937
($553)
$19,606
Plan Specific Metrics
Plan Utilizers per Disease Condition
Total Annual Savings per Disease Condition
Total Savings
2
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5
12
$10,154
$196,612
$7,880
$220,626
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($7,056)
17
$209,058
6
($3,318)
15
$294,091
$928,047
$ 15.77 PEPM Savings
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Across eight conditions; combined Medical and
Pharmacy savings
Suffolk Schools Employee Health Plan:
Overall Specialty Drug Cost Trend
For the most recent 12-month time period through June 30, 2010
combined Pharmacy and Medical cost trend is down
Specialty Pharmacy PMPM Trend
Prior
Current
Trend
Medical
$13.94
$11.11
-20.3%
Pharmacy
$18.21
$19.98
9.7%
Total
$32.15
$31.09
-3.3%
Plan Benefits
• Improved patient’s knowledge and
understanding of disease and its therapy
• Improved compliance rates (adherence)
• Appropriate duration of therapy
(persistence)
• Reduced overall plan costs for specialty
medications
Montana Association of Health Care Purchasers
Don Creveling, MBA
Executive Director, MAHCP
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Actual Total Cost
Whether buying or selling,
price is only a part of the
actual total cost.
Costs of quality including
paying for outcomes, and costs
of the transaction including
resources, effort, time, payment
terms, and renegotiations must
be considered when assessing
or comparing actual total
costs of propositions, products
or services.
price
value
Unit Cost
The right product at the
right time and place
(quality & outcome)
transaction
Cost of resources,
effort, time, and doing
business
© Christopher Barrat & Alan Chapman 2004, from the free resources website www.businessballs.com.
MAHCP
3 Primary Coalition Functions:
1) 501 (c) 6 joint purchasing coalition (1991)
– Comprised of public & private corporations (by statute)
2) Data warehouse and analytics shop for all member health
benefit plan data (2002)
3) Education & benefits discussion forum
Mission
Provide economy of scale, independent/combined data &
analytic resources and related forum for all member plans
***Important note: We work for the EMPLOYER
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Pharmacy Benefit Management (PBM)
Programs
• Where it began
– History of PBM contracts with MAHCP previous and current PBM’s
• Traditional PBM programs
• Urx Program
– PBM / PBA program
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Direct Contracting with Mail Order (MO)
Pharmacies
•
•
•
•
•
Coalition signed contact with MO pharmacy
“Cost Plus” contract
Pricing Method
Recon process
Results
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Brian Davis, Director
Timber Products Manufacturers Trust
Retrospective Safety Review
Drug Savings Reviews
Other Incremental Programs
On the Horizon: Pharmacy Advisor Program
TPM Trust
•
•
•
•
Multi Employer Health Trust
Started 1964
Based in the Northwest (5 states)
Covering a wide variety of Employers
working in and serving the Wood Products
Industry
What Happened
• Housing Slump Hit our Members Hard
• Attrition Created Accelerated Aging in
Workforce
• Utilization Increased Dramatically Relative
to contributions
• Industry Use of Heavy Equipment and
Aging Workforce created Drug Safety
Issues
Approach
• Steps Needed to Improve Utilization
Management and Control Costs
• No Silver Bullet
• Began working more closely with PBM
Account Team to find solutions
• Began Adding Several Programs
Incrementally
• Keep Perceived Member Impact Low
Retrospective Safety Review
• Focus on Participant Safety
• Retail and Mail Prescriptions reviewed daily for:
– Therapeutic duplication management
– Age appropriate management
– Duration therapy concerns
• Prescriber receives communication identifying
– Clinical issues
– Suggestions to Improve Medication Therapy
Retrospective Safety Review
• Value
– Real Time Review and Intervention
– Increased Safety
– Increased Prescriber Engagement
– Early Savings Capture
– Total Savings: 1.5% of Gross Spend
Drug Savings Review
• Retrospective Claim Edits are processed for retail and
mail service claims in these areas of focus
– Appropriate therapy management
– Condition Management
– Dose Optimization
– GI Therapy Management
• Prescribers contacted within 72 hours of claim making
recommendations utilizing plan participant-specific;
evidence based recommendations
Drug Savings Review
• Value
– Real time review and intervention
– Early savings capture
– Increased Prescriber Engagement
– Total Savings: 3%
Other Incremental Programs
•
•
•
•
•
Incentivized Mail
Generic Co Pay Incentive
Quantity Limits
Dose Optimization
Total Savings: 2.8%
Questions?
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