Rising Pharmacy Cost:
Alternatives to Managing Trend
Juan M. Cruz Orta
October 24th, 2019
Main Objective
This session will examine pharmacy market trends and legislation in Puerto Rico and will discuss alternatives to control cost particularly in the specialty pharmacy landscape.
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Specialty Drugs
Specialty pharmaceuticals could be defined as "high-cost oral or injectable medications used to treat complex chronic conditions".
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Specialty Drugs
0
100
200
300
400
500
600
1990 1995 2008 2015 2018
Specialty Drugs in the Market
1030
200
300
500
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Most Common Specialty Medications
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$4,797RA/PsA/CD
$4,264RA/PsA/PsO
$6,954Multiple Sclerosis
$5,760Multiple Sclerosis
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$11,330Multiple Myeloma
$13,038PsA/PsO/Crohn’s
$11,911Prostate Cancer
$33,293Hereditary
Angioedema
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$850,000Inherited Retinal
Disease
$750,000 initial + $375K follow-upSpinal Muscular
Atrophy
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Rising Pharmacy Costs:
Alternatives to
Managing Trend
Eduardo Zetina
October 24th, 2019
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U.S. (84% GDR)
Canada (70% GDR)
France (30% GDR)
Australia (37% GDR)
Source: The Commonwealth Fund Oct-2017
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This hits Puerto Rico even harder
Rx is20% of
Total Spend
Rx is33% of
Total Spend
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Rx Net Pricing: U.S. vs Other Countries
Budget for Price Discounts
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Puerto Rico by the numbers…
• Private health insurance market in Puerto Rico represents about $2.3 billion in annual expenditures.
• Prescription Drugs account for about one third of those expenditures, or about $750 million per year.
• Specialty Medications (Biologics) account for less than 2% of all prescriptions filled, yet they account for a whopping 35% of all Rx dollars, or about $260 million per year in the PR commercial market alone.
• Average Specialty Rx now exceeds $4,000/month.
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How are health insurancepremiums affected?
There are two (2) fundamental problems with the way the cost of these vital treatments are factored into our health insurance premiums:
1. They are NOT evenly dispersed among medium-sized employer groups, and
2. Once identified, they are highly repetitive and are therefore automatically priced into the group’s renewal premiums.
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Case Study of a High-Impact Rx Drug on Renewal
• Employer Group Plan with 250 employees and a Premium Rate of $400 PEPM
• Monthly Premium is $100,000 (250 employees x $400 Premium Rate)
• Monthly Claims average approximately $85,000—an MLR of 85%.
• A dependent is diagnosed with Hemophilia A and now needs Clotting Factor VIII replacement therapy at a cost of $45,000 per month.
• Average Monthly Claims for the Group just went from $85K/month to $130K/month—and the Group’s MLR went from 85% to 130%, prompting a renewal rate increase of +60% to cover the cost of the new risk level.
• All other insurance carriers on the island react in the same way, offering rates ranging from +50% to +70%.
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Can we mitigate the impact through Member Cost-Share?
(Specialty Coinsurance)
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What about the
MOOP?
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The unintended consequence of the MOOP
• The MOOP is the Maximum Out-of-Pocket member expense per year (locally $6,350 for Indiv contracts / $12,700 for Non-Indiv contracts).
• In Puerto Rico, by far the most common occurrence of Member Cost-Sharing exceeding the MOOP threshold is in Specialty Medutilization.
• Because most Specialty Meds have Copay Assistance Programsin place, the MOOP ends up creating an unintended cap on the benefit the Pharmaceutical Industry offers.
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Example:$10,000/month Medication
under a 30% Coinsurance
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Monthly Cost Plan Share Member Share Plan % of Tot Cost
Jan $10,000 $7,000 $3,000 70.0%
Coinsurance applied
effectively for the month of
January.
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Monthly Cost Plan Share Member Share Plan % of Tot Cost
Jan $10,000 $7,000 $3,000 70.0%
Feb $10,000 $7,000 $3,000 70.0%
Coinsurance applied
effectively for the month of
February.
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Monthly Cost Plan Share Member Share Plan % of Tot Cost
Jan $10,000 $7,000 $3,000 70.0%
Feb $10,000 $7,000 $3,000 70.0%
Mar $10,000 $9,650 $350 96.5%
Effective Coinsurance
reduced to only 3.5% for the month of March (member
accumulator reached the
MOOP).
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Monthly Cost Plan Share Member Share Plan % of Tot Cost
Jan $10,000 $7,000 $3,000 70.0%
Feb $10,000 $7,000 $3,000 70.0%
Mar $10,000 $9,650 $350 96.5%
Apr $10,000 $10,000 $0 100.0%
May $10,000 $10,000 $0 100.0%
Jun $10,000 $10,000 $0 100.0%
Jul $10,000 $10,000 $0 100.0%
Aug $10,000 $10,000 $0 100.0%
Sep $10,000 $10,000 $0 100.0%
Oct $10,000 $10,000 $0 100.0%
Nov $10,000 $10,000 $0 100.0%
Dec $10,000 $10,000 $0 100.0%
TOT $120,000 $113,650 $6,350 94.7%
Full-year effective coinsurance drops to a mere 5.3%.
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Monthly Cost Plan Share Member Share Plan % of Tot Cost
Jan $10,000 $7,000 $3,000 70.0%
Feb $10,000 $7,000 $3,000 70.0%
Mar $10,000 $7,000 $3,000 70.0%
Apr $10,000 $7,000 $3,000 70.0%
May $10,000 $7,000 $3,000 70.0%
Jun $10,000 $7,000 $3,000 70.0%
Jul $10,000 $7,000 $3,000 70.0%
Aug $10,000 $7,000 $3,000 70.0%
Sep $10,000 $7,000 $3,000 70.0%
Oct $10,000 $7,000 $3,000 70.0%
Nov $10,000 $7,000 $3,000 70.0%
Dec $10,000 $7,000 $3,000 70.0%
TOT $120,000 $84,000 $36,000 70.0%
Very different from the intended result!
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Legislative Solution?
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Example: Senate Bill 1204
▪ Reduce Base Cost of Specialty Medications – the bill makes reference to a uniform 40% coinsurance with the specific intent of allowing the pharmaceutical industry’s Copay Assistance Programs to fully cover the member cost-share without being accumulated toward the MOOP.
▪ Mandatory Specialty Medication Reinsurance Program – the bill also creates an island wide reinsurance coverage that assumes the risk for 90% of the cost of Specialty Medications in excess of the first $600 per drug per month, for all fully-insured commercial health insurance in Puerto Rico. The bill excludes Medicare and Medicaid programs.
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Example: Senate Bill 1204
• The legislation effectively reduces the base cost of Specialty Meds by allowing Copay Assistance Programs to do their job, while also diluting the cost even further by pooling Specialty Med risk among ALL commercial members.
• More important, it actually promotes the use of Specialty Meds among the patients that most need them by not directly penalizing group plans that have those patients, during the group’s renewal rating process.
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Revised Case Study of a High-Impact Rx Drug
• Employer Group Plan with 250 employees and a Premium Rate of $400 PEPM
• Monthly Premium is $100,000 (250 employees x $400 Premium Rate)
• Monthly Claims average approximately $85,000—an MLR of 85%
• A dependent is diagnosed with Hemophilia A and now needs Clotting Factor VIII replacement therapy at a cost of $45,000 per month
• Under Mandatory Reinsurance, this amount is reduced to $5,040 per month (the first $600 + 10% of the excess)
• Average Monthly Claims for the Group go from $85K/month to $90K/month—and the Group’s MLR went from 85% to 95%, resulting in a more reasonable rate increase of +12% to 15% to cover the cost of the new risk level and reinsurance.
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Thank you!
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Managing Pharmacy Trend: Understanding the Need for Clinical
Management & Health Data Integration
Luis Pérez Moreno, MD, MPH, MHSA
October 24th, 2019
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Discussion Topics
• Relevant Demographic and Epidemiologic Data Points for Puerto Rico
• Health Care & Pharmacy Trends in Puerto Rico
• Smart Pharmacy Benefit Design
• New Trends in Pharmacy Management:
– Price Transparency, Clinical Management and Health IT
– Prevention and Chronic Condition Management
• Closing Remarks
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DEMOGRAPHIC SHIFTAdding great stress to an already fragmented
health care system
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Source: U.S. Census Bureau, International Data Base, Demographic Overview (Puerto Rico).
Puerto Rico has already begun its Demographic Shift
Source: U.S. Census Bureau, International Data Base, Demographic Overview (Puerto Rico).
Puerto Rico’s Median Age = 42.7 yrs.
Population Pyramid:Change over the Past Decade 2006 - 2017
EPIDEMIOLOGYChronicity of disease and the need for a
more integrated system
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Puerto Rico Major Causes of Death:Absolute Frequency
Puerto Rico Major Causes of Death: Percentage Change 2015 - 2017
Puerto Rico
Puerto Rico Diabetes Prevalence
Puerto Rico Cancer Incidence:5-Yr. Change
Alzheimer’s Rates by Regions(Per 1,000 persons aged 60 or older)
Alzheimer's Disease Registry (as of 12/31/2017); Puerto Rico Department of Health
HEALTH CARE & PHARMACY TRENDS
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Puerto Rico’s Health Care Spend Breakdown
• Total Annual Health Care (HC) Spend = $12,000 M
• Total HC Expenditure as % of GDP = 11.5%
• Total Annual Pharmacy Market = $4,000 M (33%)
– Commercial Health Plans = $1,602 M
– Medicare Advantage Plans = $1,558 M
– Medicaid (Vital) Rx Spend = $840 M
FARO, LLC 44
Total Puerto Rico Pharmacy Market $3,898 M
+2.0%
IQVIA / Peterson-Kaiser Health System Tracker / FARO, LLC
2018
$3,822 M
2017Rev.
+1.5%
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Retail Pharmacy Rx Rankings:Puerto Rico’s Rx Mix Drives Increased
Utilization and Costs
IQVIA46
Traditional Pharmacy:Puerto Rico Top 20 Products Rank Comparison
IQVIA47
Top-5 Specialty Drug Therapeutic Areas Top 5 SPP (Non Retail) USC2 Markets Based on MAT Sales and Growth
Source: Puerto Rico MVP (SMART PR) December 2017 Data Month
$230
$176
$96
$57
$2316%
9%
16%
4% 4%0%
10%
20%
30%
40%
50%
60%
70%
80%
$0
$50
$100
$150
$200
$250
MA
T G
row
th
Mil
lio
ns
Sales $ Volume
Sales $ Growth
IQVIA48
Specialty Pharmacy: Top-15 Change in Value Products
IQVIA49
SMART PHARMACY BENEFIT DESIGN
Benefits 2.0
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Drug Pricing:Who Sets Drug Prices?
• Generic Drugs
– Local Drug Wholesalers
– Supply and Demand Economics
– Price hikes controlled using the Maximum Allowable Cost (MAC)
• Branded & Specialty Drugs
– Drug Manufacturers based on the value of innovation
– What the market can bear philosophy
– Price hikes controlled using rebates
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Drug Pricing:Benchmark Definitions
• Average Wholesale Price (AWP)– Used to reimburse pharmacies for drug dispensing
– Used to calculate contract guarantees for PBMs
– AWP inflation usually outpaces WAC pricing
• Impacts value of negotiated drug rebates
– +20% than WAC ($100 AWP Drug = $80 WAC Drug)
• Wholesale Acquisition Cost (WAC)– List Price of drug
– Price paid by pharmacies to acquire drugs (COGS)
– Used to calculate drug rebates by the PBM
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Puerto Rico Average Cost Per Claim
• Generic Drugs (Multi-Source) = $20
• Brand Drugs = $350
• Specialty Drugs = $4,600
FARO, LLC / Wolters Kluwer 53
Pharmacy Benefit Managers (PBMs)
1. Administrative Fee (PMPM, PEPM, Per Claim) –Processing Claims, Network and Formulary
2. Network Guarantees (Off of AWP Discount Rates)
3. Rebate Guarantees ($ Per Branded Claim)
4. Clinical Programs and IT Services
5. Pharmacy Audits
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Traditional “Go To” Strategies Don’t Work in the Specialty Game
• Employer contribution to the health insurance
• Copays, Coinsurances and Limits
• Generic Dispensing (GDR)
• Utilization Management Edits (ST, QL, Duplicate Therapy)
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Value of a Good Benefits Broker/Consultant
1. Understands group’s epidemiologic profile by leveraging its raw claims data set
2. Applies managerial epidemiology principles to effectively improve the employer’s population health
3. Defines new clinical protocols for chronic conditions that are prevalent inthe group – Communicates to Insurer
4. Mines the claims data set to flag early signs of chronic-debilitating conditions (Tertiary Prevention)
5. Pushes Primary and Secondary Preventative Practices in the group
6. Understands drug economics, PBM science, Specialty trend and value-based arrangements
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Pharmacy Trend Management 2.0:Basic Levers
3. Pharmacy Carve Outs & Employer Drug Rebate Negotiations
2. Pharmacy Network Design (Behavioral Economics)
1. Formulary Management
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Pharmacy Trend Management 2.0:Generic Drug Inflation Management
Driving Consumer Decisions: The Need for our own Version of a Reference Pricing Model
LOCAL APPLICATION▪ In situations where there is wide price variation for therapeutically similar drugs.▪ Individual drugs are grouped according to therapeutic class and payment is limited to the price of the least expensive alternative in each
class.
Row Labels Average of GROSS_DUE_AMOUNT Max of GROSS_DUE_AMOUNT Min of GROSS_DUE_AMOUNT
ACE inhibitors $11.38 $271.74 $1.36
Statins $18.36 $526.33 $1.00
TARGET THERAPEUTIC CLASSES (AVG. ANNUAL PLAN PAID +$800K)
Median monthly price variation = $384.17
Drug Claims % of Total Comments
ACE inhibitors 37,047
ENALAPRIL 16,312 44% More Expensive Drug
LISINOPRIL 11,381 31% Reference Drug
Statins 89,011
ATORVASTATIN 40,641 46% More Expensive Drug
SIMVASTATIN 27,922 31% Reference Drug
LOVASTATIN 472 1% Reference Drug
Demonstrates limited ability of a tiered formulary to influence decisions based on price
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Pharmacy Trend Management 2.0:Generic Drug Inflation Management
Driving Consumer Decisions: The Need for our own Version of a Reference Pricing Model
Drug Ref Drug Patients Claims Patient Paid Plan Paid New Plan Paid Diff Plan Paid
Avg INGREDIENT
COST PER UNIT
Avg REF INGREDIENT
COST PER UNIT
ACE inhibitors 5,148 25,666 $128,541.83 $340,514.66 $127,401.23 ($213,113.43) $0.34 $0.128
ENALAPRIL 3,436 16,312 $76,571.66 $221,925.61 $87,549.05 ($134,376.56) $0.34 $0.127
CAPTOPRIL 119 617 $1,962.96 $39,713.25 $11,333.53 ($28,379.72) $0.97 $0.103
RAMIPRIL 1,169 6,276 $32,956.97 $38,548.09 $15,548.17 ($22,999.92) $0.23 $0.133
VASOTEC 4 20 $2,642.32 $14,896.93 $3,754.63 ($11,142.30) $15.89 $0.108
ALTACE 10 37 $1,853.07 $9,858.27 $1,452.18 ($8,406.09) $6.60 $0.155
FOSINOPRIL 118 653 $2,761.17 $4,725.03 $2,463.05 ($2,261.98) $0.24 $0.125
QUINAPRIL 165 905 $4,418.03 $4,463.75 $2,660.78 ($1,802.97) $0.19 $0.132
ACCUPRIL 3 15 $1,444.40 $2,244.50 $447.79 ($1,796.71) $4.38 $0.129
TRANDOLAPRIL 72 454 $2,461.67 $2,664.90 $1,173.93 ($1,490.97) $0.26 $0.113
BENAZEPRIL 80 363 $1,359.58 $1,271.94 $987.17 ($284.77) $0.13 $0.132
PERINDOPRIL 2 14 $110.00 $202.39 $30.95 ($171.44) $0.65 $0.113
Statins 6,537 25,732 $128,637.40 $528,622.31 $243,745.54 ($284,876.77) $0.62 $0.248
ATORVASTATIN 3,816 15,058 $49,838.04 $228,325.76 $120,408.82 ($107,916.94) $0.44 $0.203
SIMVASTATIN 1,303 4,949 $37,813.55 $136,422.97 $63,109.44 ($73,313.53) $0.90 $0.392
ROSUVASTATIN 589 2,059 $10,643.58 $78,107.22 $27,637.82 ($50,469.40) $1.08 $0.277
PRAVASTATIN 884 3,451 $17,378.20 $64,410.83 $28,763.50 ($35,647.33) $0.57 $0.229
CRESTOR 15 42 $6,049.65 $10,567.63 $2,064.46 ($8,503.17) $8.87 $0.364
LIPITOR 11 33 $4,991.61 $6,332.26 $427.21 ($5,905.05) $9.24 $0.457
PRAVACHOL 3 25 $1,514.68 $3,699.98 $817.29 ($2,882.69) $4.68 $0.381
LOVASTATIN 29 114 $162.68 $755.66 $517.00 ($238.66) $0.14 $0.092
ZOCOR 1 1 $245.41 $0.00 $0.00 $0.00 $8.11 $0.416
Grand Total 10,814 51,398 $257,179.23 $869,136.97 $371,146.77 ($497,990.20) $0.48 $0.184
Drug Ref Drug Patients Claims Sum of Claims Patient Paid Plan Paid New Plan Paid Diff Plan Paid
Avg INGREDIENT
COST PER UNIT
Avg REF
INGREDIENT
COST PER UNIT
ACE inhibitors 5,148 25,666 49.94% $128,541.83 $340,514.66 $127,401.23 ($213,113.43) $0.34 $0.128
ENALAPRIL 3,436 16,312 63.55% $76,571.66 $221,925.61 $87,549.05 ($134,376.56) $0.34 $0.127
ENALAPRIL TAB 10M LISINOPRIL TAB 20M 859 3,923 100.00% $25,227.36 $29,665.81 $10,237.45 ($19,428.36) $0.28 $0.116
ENALAPRIL TAB 2.5 LISINOPRIL TAB 5MG 339 1,471 100.00% $6,774.45 $5,021.63 $1,546.77 ($3,474.86) $0.15 $0.106
ENALAPRIL TAB 20M LISINOPRIL TAB 40M 692 3,304 100.00% $22,201.02 $44,793.00 $17,339.30 ($27,453.70) $0.36 $0.153
ENALAPRIL TAB 20MG LISINOPRIL TAB 40M 1 1 100.00% $6.00 $40.78 $6.77 ($34.01) $0.52 $0.142
ENALAPRIL TAB 5MG LISINOPRIL TAB 10M 605 2,669 100.00% $16,684.19 $17,517.95 $5,758.94 ($11,759.01) $0.26 $0.107
ENALAPRIL MALEATE 10 MG TAB LISINOPRIL TAB 20M 394 1,586 100.00% $1,825.37 $34,790.27 $14,541.33 ($20,248.94) $0.45 $0.119
ENALAPRIL MALEATE 2.5 MG TAB LISINOPRIL TAB 5MG 114 394 100.00% $480.37 $5,746.85 $2,606.74 ($3,140.11) $0.32 $0.105
ENALAPRIL MALEATE 20 MG TAB LISINOPRIL TAB 40M 418 1,862 100.00% $2,017.20 $57,536.10 $25,766.81 ($31,769.29) $0.54 $0.156
ENALAPRIL MALEATE 5 MG TABLET LISINOPRIL TAB 10M 267 1,102 100.00% $1,355.70 $26,813.22 $9,744.94 ($17,068.28) $0.50 $0.108
CAPTOPRIL 119 617 2.40% $1,962.96 $39,713.25 $11,333.53 ($28,379.72) $0.97 $0.103
CAPTOPRIL TAB 100M LISINOPRIL TAB 20M 2 8 100.00% $31.69 $0.25 $0.25 $0.00 $0.05 $0.115
CAPTOPRIL TAB 12. LISINOPRIL TAB 2.5 15 80 100.00% $444.04 $650.20 $215.54 ($434.66) $0.21 $0.061
CAPTOPRIL TAB 25M LISINOPRIL TAB 5MG 27 126 100.00% $731.77 $889.23 $334.61 ($554.62) $0.20 $0.106
CAPTOPRIL TAB 50M LISINOPRIL TAB 10M 15 78 100.00% $571.80 $3,591.43 $741.10 ($2,850.33) $1.00 $0.107
CAPTOPRIL 100 MG TABLET LISINOPRIL TAB 20M 14 82 100.00% $20.00 $13,050.77 $3,849.04 ($9,201.73) $2.04 $0.119
CAPTOPRIL 12.5 MG TABLET LISINOPRIL TAB 2.5 2 15 100.00% $0.00 $775.95 $227.13 ($548.82) $0.86 $0.062
CAPTOPRIL 25 MG TABLET LISINOPRIL TAB 5MG 16 86 100.00% $78.00 $5,151.97 $1,743.23 ($3,408.74) $0.95 $0.106
CAPTOPRIL 50 MG TABLET LISINOPRIL TAB 10M 34 142 100.00% $85.66 $15,603.45 $4,222.63 ($11,380.82) $1.52 $0.108
RAMIPRIL 1,169 6,276 24.45% $32,956.97 $38,548.09 $15,548.17 ($22,999.92) $0.23 $0.133
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Drug Ref Drug Patients Claims Sum of Claims Patient Paid Plan Paid New Plan Paid Diff Plan Paid
Avg INGREDIENT
COST PER UNIT
Avg REF
INGREDIENT
COST PER UNIT
ACE inhibitors 5,148 25,666 49.94% $128,541.83 $340,514.66 $127,401.23 ($213,113.43) $0.34 $0.128
Statins 6,537 25,732 50.06% $128,637.40 $528,622.31 $243,745.54 ($284,876.77) $0.62 $0.248
POTENTIAL SAVINGS*
ADDITIONAL NOTES
▪No formulary or benefit design changes are needed initially to do a reference pricing pilot▪All generic claims consider existing MAC pricing▪Patient will always have at least 1 reference product alternative to choose within each therapeutic class▪ Important to leverage e-Rx and EHR to ensure timely pricing information (”pricing transparency”) and exception documentation for
prescribing physician▪Reference pricing needs to be embedded within a larger reimbursement framework– focus on lowering total cost of care (E.g., Shared
Saving models)▪Reference pricing can be used with Specialty medications only if comparative effectiveness models are considered
*Model assumes 20% clinical exception approval.
Pharmacy Trend Management 2.0:Generic Drug Inflation Management
Driving Consumer Decisions: The Need for our own Version of a Reference Pricing Model
60
Pharmacy Trend Management 2.0:Formulary Management & Rebates Contracting
Cost Effectiveness Analyisis
Effectiveness
Effectiveness
61
Pharmacy Trend Management 2.0:CEA Rheumatoid Arthritis
62
NEW TRENDS: PRICE TRANSPARENCY,
CLINICAL MANAGEMENT & HEALTH IT
63
Physician Drug Price Transparency:Biosimilars for Inflammatory Bowel Disease
1. Patient with Inflammatory Bowel Disease: Anti-TNF (Remicade
vs Renflexis)• Patient:
o Female, 35 years old
o Frequent, recurring diarrhea & Rectal bleeding
o Unexplained weight loss & Reduced appetite
o Fatigue and a feeling of low energy
• Primary Dx.: K50.011 Crohn’s disease of small intestine with rectal
bleeding
• Secondary Dx.:
o K50.018 Crohn’s disease of small intestine with other
complication
o M81.8 Other osteoporosis without current pathological fracture
o E78.5 Hyperlipidemia, unspecified
• Medications:
Drug Name NDC
AZATHIOPRINE TAB 50MG 60219107601
EZETIMIBE TAB 10MG 00781569031
METHYLPR SS INJ 125MG 25021080810
REMICADE INJ 100MG 57894003001
SIMVASTATIN TAB 20MG 00093715410
METRONIDAZOL TAB 250MG 75834010701
• Physician will change treatment to the new FDA approved Biosimilar for Remicade which has been included in the Insurance
Plan’s formulary, “RENFLEXIS 100 mg/1” (NDC: 00006430502). Physician understood that the drug cost would be lower with the
biosimilar. Upon prescription of Renflexis the following message will appear: “Please consider prescribing REMICADE INJ
100MG, which has an overall lower net cost driving material savings for the Health Plan considering current rebate
agreements with manufacturer"
Note: Patient will not be impacted negatively by Physician’s choice of prescribing Remicade due to the manufacturer’s
existing Patient Support Programs.
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Real Time Physician EHR Information:Type 2 Diabetes Mellitus
65
NEW TRENDS: PREVENTION & CHRONIC
CONDITION MANAGEMENT
66
Doing a Deep Dive:Employer’s Claims Data Set
67
Consensus
Clinical Guideline
Health System
Transformation FrameworkOutputs
Delivery
ModelFinancial Metrics
Social
DeterminantsActuarial Analysis
Performance
Measures
Epidemiologic
Analysis
Health Economic
AnalysisQuality Measures
Workforce
Elements Perspectives
Health Outcomes
Measures
Social
- QoLClinical
Structural System
Elements Labor
Productivi
ty
Customized
condition
management
algorithm(employer group)
Resultin
g
Benefit
Standardization of
clinical
management &
metrics
Replication
through-out
Provider Network
Lower Costs &
Better
Outcomes
On-site /
Telemedicine
Population Health ToolsClinical Management Algorithm: Design Process
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Prevention & Chronic Disease Management:Rheumatoid Arthritis
On-site PCPprepares Referral
Package for Network
Rheumatologist
Rheumatologist follows ACR
guidelines and applies T2T
Employee w/ suspected RA
If disease flares and becomes
active (RAPID3)
If employee achieves
remission/ LDAS
On-site Primary Care Physician
Swollen joints, + Squeeze, Morning Stiffness
Hx. (Comorbidity), RF, ACPA, ESR,
CRP
Rheumatologist evaluates
Employee looks for signs of ERA
or VERAJoints, serology, acute
phase reactants, duration Sx.
If definitive RA (+Dx.)
DMARD Mono Tx., routinely measures & documents disease activity
(3 - 6 mo in remission/LDAS) – RAPID 3
<30 days
Definitive RA criteria (ACR/EULAR)
Rheumatologist refers Pt. to care
of PCP “0 – 3” disease activity scale
Monitor RA using RAPID3 (3-6 mo), documents, as well as
manages comorbidities
Rheumatologist validates
MDAS/HDAS, applies T2T
Monthly consultations and follow-up, starts combination Tx. Regimen, and monitors w/
RAPID 3
Employee shows signs of
improved disease activity
Rheumatologist – Clinical
judgement
Closely monitors every 3 - 6 mo or
refers back to On-site PCP
On-site PCPconsiders low
dose steroids/MTX tapering, and
refers to Rheumatologist
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CLOSING REMARKSGRACIAS!
70