Trend Drivers & Innovation in Pharmacy Benefit Management
Marly ArbuckleSpecialty Products & Affairs DirectorMedTrakRx
Today’s presenters
Kelly ChillingworthSenior Vice PresidentPharmacy Practice LeaderLockton
Sherry PateDirector - Human Resources Total Comp & HRISINTRUST Bank
What is a “carve-out”?Drug Companies –
Rx Rebates MTM VendorPharmacy 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 1,334Paid 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 SolutionsPossible 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
Pipeline01• Targeted therapies• Gene therapies• Rare, orphan and ultra-orphan conditions• Oncology• Peanut allergy• $$$$$
Medical Drug Channel Management02• 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 Programs03• Members artificially meet deductibles and OOPs• Plans pay more earlier in plan year• Members don’t understand true cost of therapy
Biosimilars & Specialty Generics04• 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 aremy 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 StrategiesSpecialty 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 SpecialtyRxNetwork 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-FocusedClinical Controls Individualized Care True Integration Meaningful Data
Focus on Member Experience
8secondsAverage Speed
of 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.
HemophiliaPatient 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 RatesBIC 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?