Speaker Brian K. Solow, MD, FAAFP Optum Life Sciences Irvine, CA, USA PBMs: Impact on Cost and Quality of Pharmaceutical Care in the U.S. Brian K. Solow, MD, FAAFP Chief Medical Officer, Optum Life Sciences ISPOR 19th Annual European Congress, Vienna, Austria November 2, 2016 2 1
What is a PBM? A PBM is a Pharmacy Benefit Manager company that administers drug benefit programs for employers and health plans. PBMs provide programs and services designed to maximize drug effectiveness and manage drug expenditures by appropriately influencing the behaviors of Prescribing Physicians Pharmacists Clients Members 3 What is a PBM? PBMs are primarily responsible for: Processing and Paying Prescription Drug Claims Contracting with a Network of Pharmacies Developing and Managing Drug Formularies and Clinical Quality and Utilization Negotiating Discounts and Rebates with Drug Manufacturers A PBM may provide these services on behalf of health insurance companies, employers, unions, or any other organization offering prescriptions benefits. 4 2
How Does a PBM Work? High-level Value Chain PREMIUMS PATIENT HEALTH PLAN FILLED PRESCRIPTION COPAYMENT ADMIN FEE SHARE OF MANUFACTURER REBATES PHARMACY CLINICAL SERVICES PHARMACY CLAIMS PROCESSING PHARMACY CUSTOMER SERVICE NEGOTIATE NETWORK DISCOUNTS Rx DISPENSING FEES PBM Rx COPAYMENT RETAIL PHARMACY NEGOTIATED PRICE DISCOUNTS PHARMACY BENEFIT MANAGER MAIL ORDER PHARMACY PRESCRIPTION DELIVERED TO HOME PATIENT S HOUSE PLACE ON FORMULARY NEGOTIATED REBATES PHARMACEUTICAL MANUFACTURER Physician and Patient reactions to PBMs Physicians You re wasting my time! But my patient is different! Just who do you think you are, telling me how to practice medicine? Patients You ve never even seen me before! You re not a doctor. My physician knows me best. I pay good money for my drug benefit! (entitlement mentality) 6 3
Driving Clinical Excellence Through the Experience Achieving Optimal Health Specialty Pharmacy Care Management Utilization Management Collaborative Fulfillment Condition Management Education Medication Compliance Program Clinical Management Maximizing Savings Drug Formulary Management Formulary Education Initiative Pipeline Drug Forecast Prior Authorization Clinical Edits Generics Medication Utilization Mail Service Pharmacy Program - Preferred Mail Creating Customized Solutions Consultative Analysis Predictive Modeling for Clinical Savings Improving Quality and Safety Disease-Specific Clinical Drug Interaction Alert Program Geriatric RxMonitor Program Polypharmacy Program Quality Improvement Initiatives (HEDIS) Medication Therapy Management Member Education Adherence/Refill Reminder Comprehensive Audit Program Narcotic Drug Utilization Review Program 7 Clinical Affordability Benefits of Utilization Management Step Therapy Provide opportunity for member savings by using more cost-effective medications Reduced pharmacy costs Improved formulary management and positioning Prior Authorization Increased formulary awareness and positioning through clinical criteria that promote safe and effective medication use Improved quality of member care by using evidence-based criteria to promote appropriate use of certain medications Reduced inappropriate use of these medications which generates cost savings Quantity Limits Improved quality of member care through prevention of excessive dosages Minimized potential misuse and abuse of certain medications Reduced pharmacy plan medication costs through dose optimization Reduced pharmacy claim submission errors related to medication quantity by dispensing pharmacies 8 4
Concurrent Drug Utilization Review (CDUR) Program Purpose Improve the safety, appropriateness, and cost effectiveness of drugs by ensuring that prescriptions are medically appropriate at the point-of-service. How It Works Client-implemented edits are set up in RxCLAIM designed to check the member s prescription history for possible drug conflicts, such as drug-to-drug interactions, high dose, or therapeutic duplications. Prescriptions that trigger these edits will result in a claim reject or a message to the pharmacy to resolve the drug conflict. Quarterly and Year-to-Date Reports Pharmacy alerts: Number of prescriptions that triggered DUR edits at the point-ofservice Successes: Number of triggered prescriptions that result in a resolution of the drug conflict Pharmacy overrides: Number of rejected prescriptions that were overridden by the pharmacy 9 CDUR Program Example Impact and Financial Results - Q4 2013 Pharmacy Alerts, Successes and Cost Savings DUR Category Pharmacy Alert Count Success Count Adverse Drug Interaction (DDI) 4,454,154 505,641 Drug Age Consideration 874,078 43,669 Drug Gender 5,027 323 Drug Pregnancy 16,184 1,204 Drug Therapy Duplication 2,765,478 188,649 Excessive Dosing 173,749 56,150 Misuse/Abuse 54,950 12,982 Pharmacy Overrides Totals 8,343,620/75 M 808,618 DUR Category Pharmacy Alerts Pharmacy Overrides Severe Drug to Drug Interaction (DDI) 98,621 59,311 Dosechek (HD) 594,008 185,477 Refill too Soon (ID) 1,902,065 44,956 10 5
Retrospective Drug Utilization Review (RDUR) Overview RDUR is designed to ensure appropriate and safe use of medication therapy through a systematic review of medication records Program seeks to reduce the incidence of potentially inappropriate prescribing through written provider notifications Comprehensive program integrates the following categories of drug-related issues: Inappropriate dosage or duration Inappropriate age for drug use Drug-drug interactions Duplicate therapy Potential drug misuse and abuse Drug-related issues are based on quality measures and evidence-based references such as HEDIS, Micromedex, American Health Formulary Services (AHFS), and Hansten & Horn s Drug Interaction Analysis 11 Drug Interaction Alert Program (DIAP) Overview The Drug Interaction Alert Program (DIAP) addresses clinically significant drug-drug interactions (DDIs) through timely provider notification of detected DDIs. Objectives: Identify significant, patient-specific drug interactions through pharmacy claims data. Reduce the incidence of clinically significant drug interactions. Improve provider awareness of clinically significant DDIs that may arise from patients being cared for by multiple providers. Promote appropriate use of medication through provider-specific notifications and education. 12 6
PBM Savings From 2016 to 2025, the current use of PBM tools in the marketplace will save plan sponsors and consumers approximately $654 billion. Commercial plan sponsors and their members will save nearly $350 billion; Medicare Part D and its beneficiaries, nearly $257 billion; and Managed Medicaid plans, nearly $48 billion (use of PBM tools in Fee-For- Service [FFS] Medicaid is currently limited, or about 10% less than what could be achieved with the average use of PBM tools seen in other sectors). 13 14 7