Trend Drivers & Innovation in Pharmacy Benefit Management - - PowerPoint PPT Presentation

Trend Drivers & Innovation in Pharmacy Benefit Management

Marly Arbuckle

Specialty Products & Affairs Director MedTrakRx

Today’s presenters

Kelly Chillingworth

Senior Vice President Pharmacy Practice Leader Lockton

Sherry Pate

Director - Human Resources Total Comp & HRIS INTRUST Bank

What is a “carve-out”?

Drug Companies – Rx Rebates MTM Vendor Pharmacy Network PBM Vendor- Carved Out Client- ASO Employer Group

Member

Other insurance products

Medical Carrier (no Rx) Homecare Vendor(s)

Drug Companies – Medical Rebates

MD / Provider Network

Why did INTRUST consider an Rx carve-out?

$1,138,214 $1,186,350 $1,373,468 $0 $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 $1,400,000 $1,600,000 2015 2016 2017

Rx Expenses

Avg Members: 1,330 1,336 1,334 Paid PMPM: $71.32 $73.99 $85.80

How did we get started?

• Turned to our consulting team
• Clearly laid out our wish list, which included:
• Access to data
• Transparency in terms of costs and rebates
• Better understanding of rebates and the financial impact
• Pro’s and Con’s of carving in vs. carving out
• Disruption analysis
• Cost management
• Choosing a PBM that fits my needs

Benefits of Unbiased RFP Modeling

• Wide selection of PBM options, formularies, benefit designs
• PBM Summit allows for face-to-face evaluation and trust building
• Pros and cons of each vendor partner to accompany financials
• Evaluate 100% historical claims to capture drug mix, channel and brand/generic

distribution

• Apples-to-apples comparison of line items including:
• Rebate guarantees by channel (retail, mail, specialty)
• Network discounts by channel
• Administrative, dispensing, other fees by type
• Implementation credits
• Clinical savings guarantees

Cost vs. Value

• Cost was very different from traditional drugs and “value” was the sales angle
• Targeted therapies emerged with fewer side effects
• Attention to rare and formerly underserved populations
• Genetic testing to diagnose disease and treat “the right” patients
• Cost of the drug can offset future medical costs
• Gene therapies – are they truly curative? palliative?
• Are the costs and payments sustainable?
• Is the benefit exclusion of specialty or gene therapy drugs discriminatory?
• Helpful article: https://www.specialtypharmacytimes.com/news/something-has-to-

give-balancing-specialty-drug-cost-with-value/P-1

7

Utilization and Cost Drivers

• Manufacturer drug pricing increases that

potentially offset an increasing demand for rebates

• DTC (direct to consumer advertising)

for specialty and non-specialty drugs

• An aging population
• Drug innovation for rare

diseases

• Improved diagnostics including

genetic testing for specific mutations

8

Source: 2018 PBMI Research Report

Specialty Management Levers

• Pricing guarantees and rebate optimization
• Tiered formulary – preferred and non-preferred
• Formulary exclusions
• Medical vs. pharmacy benefit cost analysis
• Site of care optimization for medical specialty
• Intensive utilization management (UM)
• Prevention of waste – 30 DS limits, no auto-shipments, split fill
• Benefit design changes
• Variable copay / coinsurance programs
• Grants and pharma financial assistance
• Specialty Predictive Drug Modeler

9

Member Cost Sharing

10

Source: 2018 PBMI Research Report

Member Impact - High Cost Drugs

11

• Increased member portion can result

in non-adherence & treatment avoidance

• Fear of side effects & not

understanding proper dosing and administration can compound non- adherence.

Coinsurance and Copay Cards

12

Source: 2018 PBMI Research Report

Application of appropriate utilization management strategies Execution of specialty tiering & accumulator programs Development of strategic programs Focus on member & provider education Successful execution of site-of-care management Prior authorization & specialty pharmacy management Case management through specialty pharmacy Focus on member experience

Look for a PBM that understands the “Pain Points” of Plan Sponsors …..and provides solutions for them.

PBM Solutions Possible Pain Points

Complex drug landscape Costly medications Disincentivizing tactics Lack of education on new therapies Inconsistent payment models Waste and inappropriate use Barriers to adherence Poor customer service

Challenge: Complexities of Specialty Drug Space

Pipeline

01

• Targeted therapies
• Gene therapies
• Rare, orphan and ultra-orphan conditions
• Oncology
• Peanut allergy
• $$$$$

Medical Drug Channel Management

02

• Reimbursement varies by site of care
• Benchmark billing models vs. ambiguous “percent of charges”
• Disparities that are 3-4x cost of the drug
• Unnecessary spend under medical benefit
• Lack of proper precertification

Copay Assistance Programs

03

• Members artificially meet deductibles and OOPs
• Plans pay more earlier in plan year
• Members don’t understand true cost of therapy

Biosimilars & Specialty Generics

04

• Patent protection
• Lack of interchangeability
• Perceived lack of efficacy
• Brand loyalty
• High-cost and lack of copay cards for specialty generics
• Benefit design lack proper incentives

“How do I know if the therapy is actually working?”

“How are my members doing?”

“Are they staying out of the hospital?”

“Can you show savings?”

Challenge: Getting Basic Questions Answered

CLINICAL EFFECTIVENESS ECONOMIC IMPACT MEMBER EXPERIENCE Across the industry, plan sponsors are adopting more clinical controls and Utilization Management (UM) tactics, but should be careful as not all approaches are created equal.

Designing with Customization – Finding the Balance

Maximizing, tracking & reporting copay assistance to reflect TROOP & reduce overall plan costs Copay Management BIC Quarterly Reporting

• Utilization & trends
• Clinical management & outcomes
• Patient-level, group-level reporting
• Cost-avoidance interventions
• Individual member success stories

Strategic selection vs. global adoption Biosimilars & Specialty Generic Planning

• New-to-Market Hold
• Precision PA
• Program Development
• Formulary

BIC SpecialtyRx

Infusion Channel Management program with site of care neutral payment model Medical & Rx Alignment

Proactive Approach: Sometimes your best defense is a strong offense

Internal Strategies External Strategies

Specialty Drug Mgmt. Hand-selected network to drive cost efficiences and improve health outcomes BIC Specialty Network

 Specialized  Patient centric  Cost conscience  Innovative  Competitive  Trustworthy  Responsive  Proactive  Collaborative  Holistic

EXTENSION OF THE BENEFIT DEDICATION TO PLAN SAVINGS & COST- AVOIDANCE FOCUS ON MEMBER OUTCOMES

Best-in-Class SpecialtyRx Network

RFP Process Every 2 years Review of Clinical Processes and Programs Analysis of Discounts Rigorous Interview Process

• Member out-of-pocket costs are

reduced

• Copay assistance is tracked and

reported

• Plan pay amount per claim is

reduced

• Amounts vary, but plans can save

an average of 20% per claim

• Program is designed for non-HDHP

plans with lower specialty tier copays

• MedTrakRx manages drug list
• MedTrakRx monitors available

copay assistance

• MedTrakRx has pre-designed

specialty copay tiers

BIC Align Program

• Specialty drugs are only utilized

by less than 1% of members but contribute to nearly 45% of overall spend

• Manufacturer copay assistance is

available for most of the top- utilized specialty drugs (Hepatitis C, Inflammatory Conditions, MS, Oncology, etc.)

• BIC Align maximizes available

manufacturer copay assistance

Tracking Copay Assistance

Manufacturers offer approved patient assistance programs BIC SpecialtyRx Network pharmacies have access to manufacturer assistance programs Pharmacies connect members to programs that reduce member OOP costs Pharmacies track and report assistance to reduce overall plan costs.

Result: Cost-Effective Specialty Drug Benefit

• Disease and drug specific
• Balanced UM and formulary
• Care Management best practices
• New patient assessments
• Patient specific care pathways
• Right Med at Right Time
• More efficient PA management
• Dynamic plan design
• SOP Customizations
• Auditable reporting
• Risk profiling and gap closure
• Specialty business reviews

The BIC SpecialtyRx Program expands beyond the clinical strategies within the PBM and leverages integration with the BIC SpecialtyRx Network to provide a cost-effect specialty drug benefit. Condition-Focused Clinical Controls Individualized Care True Integration Meaningful Data

Focus on Member Experience

8seconds

Average Speed

• f Answer

97%

Member Satisfaction for 6+ years

PBA Help Desk has direct and immediate access to all functional SME’s (including Clinical) to quickly and accurately resolve issues.

Keys to Success:

• No voice response unit (VRU)
• CallTrakSM call monitoring system
• In-depth hiring & training processes – initial

and ongoing

• Proactive and empowered PBA’s provide

timely issue resolution

• Low turnover and several tenured employees

promoted to management positions

89%

First Call Resolution

Best-in-Class: Care that Goes Beyond the Patient

Multiple Sclerosis Patient is taking Glatopa and reported flushing and injection site reactions. The pharmacist provided injection training and a new injection device to alleviate the issues.

Patient no longer reports injection issues and states flushing is under control. As a result, patient is able to remain adherent to her MS therapy. Studies have shown that adherence can result in nearly 20% cost reduction to plans for fewer hospital stays, exams, and physician visits.

Hemophilia Patient is 15 years old and a new patient with the insurance and the pharmacy. Parents are Spanish-speaking only, divorced, and patient lives with his mother. Neither parent is trained to infuse, and the mother is planning a 2 week trip with no infusion support identified.

MedTrakRx worked alongside specialty infusion pharmacy partner to create a plan for home infusion and self- infusion training. A bilingual nurse was flown out to introduce the new care team, identify areas of opportunity, and train the patient and family on self-infusion. Patient is now trained on self-infusion and remains adherent to therapy.

Adherence Rates BIC Specialty Pharmacy adherence across top disease states:

95.7%

Industry average ~ 80% Medical Drug Channel Management 2019 Estimated Savings:

$3 million

Prior Authorization Approval/Denial Rates:

~20% denial rate

Internal & External Educational Initiatives

• Lunch and Learns
• C4 Flash
• BIC Bites
• Ad hoc new program rollout and training
• Webinars and in-services

Cost Avoidance Reporting: Requests for specialty drugs that were denied for inappropriate use

~$6.6M cost avoidance 2019

Total Co-Pay Trakker Savings (2019)

$21.8 M

The Value of Specialty Pharmacy Management

RFP Results and Next Steps

• Reviewed and compared responses to our RFP
• Dug in to the disruption analysis
• Application of formulary lists
• Knew the advantages and disadvantages
• Cost comparisons of admin discounts vs. rebates
• Challenges of carving out
• Advantages of carving out

Implementation & Plan Design Success

• Partnership with MTRx and Lockton was critical
• Formulary list
• Diabetes management program
• Covering compounds
• Non-essential drugs
• Pre-authorization requirements

Managing Employee Expectations

• Identified disruption vs. avoidance of disruption
• Communications - what’s the “so what” factor?
• Help members make educated decisions
• Customer service teams are enabled to solve problems

Did we make the right decision?

Avg Members: 1,330 1,336 1,334 1,341 1,382

$1,138,214 $1,186,350 $1,373,468 $1,175,501 $1,068,656

$0 $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 $1,400,000 $1,600,000

2015 2016 2017 2018 2019 Rx Expenses PMPM: $71.32 $73.99 $85.80 $73.05 $64.44

Questions?