Tips for Evolving Medicaid Pharmacy Benefits Management (PBM) Programs 1 June 5, 2015
Introductions Mark Steck Pharm.D Independent Consultant, MAXIMUS John J.P. Crouse Vice President, MAXIMUS Market Lead DecisionPoint for Pharmacy Benefits Management 2
Agenda Introductions Changes in the Medicaid Population Increasing Drug Costs Changing Technology Prescription Drug Abuse Strategies for States 3
Changes in Medicaid Populations The Medicaid population is growing and changing Total Medicaid & CHIP enrollment has grown by 19% since 2013 to over nearly 70 million people This is through both expansion and woodwork affect Fiscal 2011 data (the most current data available) Disabled 15% Elderly 9% Adults - 27% Children - 48% 4
Changes in Medicaid Populations States that have expanded Medicaid have brought new populations to the Program Childless Adult populations have brought with them a number of special cases that Medicaid had not traditionally dealt with in large numbers Hepatitis C, HIV\AIDS, Tuberculosis Some cancers Drug spend that was part of public health is now paid for by the Medicaid program 5
Changes in Medicaid Populations States have moved many enrollees to Medicaid Managed Care plans Nationally, nearly 75% of the Medicaid population now receives their medical services, and their prescription drug benefit, through a Managed Care Organization (MCO) Each MCO is free to manage their PBM program as they wish, within some limits percent of people covered by Medicaid now in some kind of managed care 6
Increasing Drug Costs Data and Trends Utilization Nationwide Part D Medicaid 1. Lipid Regulators 2. Antidepressants 3. Narcotic Analgesics 4. Beta Blockers 5. ACE Inhibitors 6. Antidiabetics 7. Respiratory Agents 11. Tranquilizers 12. Thyroid Preps 13. Calcium Antagonists 14. Antirheumatics 15. Hormonal Contraceptives 16. Angiotensin II Blockers 17. Penicillins 1. Lipid Regulators 2. ACE Inhibitors 3. Calcium Channel Blockers 4. Beta Blockers 5. Proton Pump Inhibitors 6. Thyroid Preps 7. Angiotensin II Blockers 1. Antipsychotics 2. CNS Stimulants 3. Narcotic Analgesics 4. Anticonvulsants 5. Diabetic Agents 6. Anxiolytic / Hypnotics 8. Anti Ulcerants 18. Macrolides 8. Narcotic Analgesics CDC 2014 9. Diuretics 19. Vitamins/Minerals 9. Antidepressants 10. Seizure Disorder Agents 20. Hypnotic / Sedatives 10. Seizure Disorders IMS 2015 CBO 2013 7
Increasing Drug Costs Miscellaneous Information $300 Billion in U.S. Spending Drugs as a Percent of Healthcare Spend Nationally 9.5 11% Medicaid 5% Costs Spiked in 2014 13.1% largest increase since 2003 Dispensing rates for generic drugs are similar across Medicaid FFS and Medicare Part D Drug costs are lower in Medicaid FFS than in Medicare Part D because of CMS rebates Average Cost of Drugs for Top 50 Therapeutic Classes (70% of Drug Spend) for 30 Day Supply Part D: $50 Medicaid FFS: $37 CMS Rebate Brand Drugs 23.1% Generics (and other limited categories) 13.0% Specialty Drugs in Medicaid: 2% of the Utilization / 32% of the Spend Generic Drugs: Top Ten Therapeutic Classes Rose Over 400% in 2014 8
Increasing Drug Costs Specialty Pharmacy 9
Increasing Drug Costs Specialty Pharmacy RANKED BY 2014 PMPY SPEND Trend Therapeutic Class PMPY Util. Unit Cost Total 1 Inflammatory Conditions $80.03 8.5% 15.7% 24.3% 2 Multiple Sclerosis $52.36 3.2% 9.7% 12.9% 3 Oncology $41.64 8.9% 11.7% 20.7% 4 Hepatitis C $37.95 76.1% 666.6% 742.6% 5 HIV $27.24 4.5% 10.3% 14.8% 6 Misc. Specialty Conditions $11.10 27.3% 8.2% 35.6% 7 Growth Deficiency $9.98-0.9% 7.5% 6.6% 8 Hemophilia $5.49-0.8% 17.6% 16.9% 9 Pulmonary Arterial HTN $5.41 7.6% 6.2% 13.8% 10 Transplant $5.13 0.8% -3.1% -2.3% TOTAL Specialty $311.11 5.8% 25.2% 30.9% *Am J Health-Syst Pharm. 2014; 71:e6-23 10
Increasing Drug Costs Specialty Pharmacy Specialty Drug Sampling Afatinib (Gilotrif )* Dabrafenib (Tafinlar)* Ibrutinib (Imbruvica)* Drugs Approved in 2013 / 2014 Drug Indication Cost Obinutuzumab (Gazyva)* Trametinib (Mekinist)* First-line metastatic non-small cell lung cancer with an EGFR mutation Unresectable or metastatic melanoma with BRAF V600E mutation Pts. with mantle cell lymphoma who have received at least 1 prior therapy Previously untreated chronic lymphocytic leukemia (with chlorambucil) Unresectable or metastatic melanoma with BRAF V600E mutation 11 $6,300/mo $8,600/mo $12,500/mo $12,400/mo $9,800/mo Opdivo PD-1 inhibitor $143,000/yr Sovaldi Hep-C $84K- $168K/tx Kalydeco Cystic Fibrosis $300,000/yr *Am J Health-Syst Pharm. 2014; 71:e6-23
Increasing Generic Drug Costs Almost 80% of all prescriptions dispensed as generics Cost 7,000-8,000% increases over a couple months Reasons Excuses Consolidation Raw material shortages Production run interruptions Q&A and compliance issues Bottom line: competition, it has always driven generic pricing Cost increases dramatic, but equally problematic is the velocity of the increases Impact on pharmacies Timeliness of pricing Purchase price versus reimbursement rate Access Issue (patients sent away from pharmacies) 12
Changing Technology PBM technology is fairly mature eprescribing is now pervasive and electronically transmitted prescriptions now account for roughly half of all prescriptions The next significant technology change that is emerging in the market is Electronic Prior Authorization (epa) epa has the potential to substantially change the workflow for filling prescriptions for non-preferred drugs Implementing epa allows PBMs to receive Prior Authorization requests generated within the prescribers Electronic Health Records (EHR) systems. 13
Prescription Drug Abuse Prescription drug abuse is a national problem that touches Medicaid program as well as all public and private health systems. Drug overdose is now the leading cause of death in some states surpassing motor vehicle accidents Medicaid programs are addressing the issue through utilization and fraud management and participation in State Prescription Drug Monitoring Programs (PDMP) 14
Strategies for States The Changing Role of the PBM in Medicaid Historically Through the Late 1990s: Fiscal Intermediary Role Claims Processing Rebate Processing OBRA 90 RetroDUR Early 2000s: Management of the Actual Benefit Care Management Initiatives Preferred Drug List Now Environmental Shift Changing Role Modularized MMIS Increased Managed Care Enrollment New Medical Approaches New Challenges Extension of State Medicaid Pharmacy Departments Emphasis on Program Performance Evaluation (Across FFS & MCO) Increased Need for Enhanced Analytics 15
Strategies for States Specialty Pharmacy Cost justifies individual and sub-population strategy Approach includes: Case identification Educational resources access and outreach through a Treatment Information Center Distribution management System edits/monitoring Compliance and Clinical Value Monitoring Provider contracting Limited network reduced reimbursement rate 1915(b)(4) Supplemental rebates (more efficient access greater profit opportunity) 16
Strategies for States Generic Drugs Access Improve/eliminate timing issue, access will improve Wholesaler contracting Agree to inventory levels Agree to price increase restraints Agree to restricted contracting Direct purchasing Supplemental rebates Direct purchasing Issue with limited access by providers Tipping point and mutual interest Administration analytics, monitoring, contracting 17
Strategies for States Statewide PDL / SR Preferred Drug List (Formulary) Currently MCOs Have Their Own Formularies Creates Difficulties and Administrative Challenges to Enforce Consistency and Compliance Statewide PDL Increases Rebates, Decreases Issues with Consistency Supplemental Rebates Based on PDL Above and Beyond CMS Rebates Individual MCO Formularies Fragment Buying Power (i.e., Lower Rebates) 1-2% vs 7%-8% Push Back MCOs Commercial PBMs Manufacturers 18
Questions Discussion 19
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