The Official Medtipster Blog

www.Medtipster.com Source: Wall Street Journal – Katherine Hobson, 12.12.11

We’ve written about some of the most common consumer questions about the newly launched generic version of Pfizer’s cholesterol-lowering Lipitor.

One remaining question is how much money will be saved from the generic iterations of the name-brand blockbuster — the U.S. sales of which were $7.8 billion in the year ended Sept. 30, according to IMS Health.

A group of researchers takes a stab at that issue in a perspective piece published online by the New England Journal of Medicine. Their conclusion: “the overall cost savings from the availability of generic atorvastatin are projected to reach $4.5 billion annually by 2014, equivalent to 23% of total expenditures on statins in that year.” (The aging population could mean another $30 million of cost savings annually by 2014, they note.)

To make their calculations, they looked at what happened after Merck’s Zocor lost patent protection in 2006, and also considered how the aging of the population would drive future demand for statin drugs. They predict that generic atorvastatin will “dominate the statin market as a result of patients’ switching to it from simvastatin [generic Zocor] and from [AstraZeneca’s] Crestor, and it will have an estimated market share of 44% by 3 years after market entry.”

The researchers, from institutions including the Western University of Health Sciences and Yale University, project that the price of generic atorvastatin will be 82% of the pre-generic Lipitor at the time of market entry and 49% of the brand-name after the first six months.

However, these projections come with an asterisk: they “estimate what would happen with the rapid availability and timely uptake of generic atorvastatin.” The researchers say “aggressive business tactics” used by Pfizer to keep people using name-brand Lipitor, including deals with pharmacy-benefit managers and discounts to patients, may prevent switches to the generic.

“In order to capitalize on this opportunity for cost savings from the expiration of Lipitor’s patent, there must be a rapid, concerted effort by many players in the health-care system to facilitate awareness of and access to the generic,” they write.

www.Medtipster.com Source: Terrance Killilea, Pharm.D. and Scott Haas, 12.08.11

Pharmacy benefit managers (PBMs) are contractors hired by health plans to administer health plan pharmacy benefits, and PBMs that practice spread pricing, charge plan sponsors (employers) more for prescription drugs than what’s actually paid to the pharmacy.

Spread pricing is largely unknown to employers and those who pay health bills. The practice is occasionally understood by some participants in the health system (health plans, brokers), but often not acted upon due to relationships. Spread pricing has a significant impact on health plan costs. For example, when a PBM pays a pharmacy a minor amount (say $6) for a prescription, but charges the employer and patient a much higher price (say $30). This higher amount is reflected in both the co-pay and the billing to the employer.

Clearly, this has an impact on the cost of a self-funded program, but it also impacts the premiums of fully insured programs through experience. Health plans providing fully insured coverage, where spread pricing is occurring, either do not know about spread pricing or know about it and share in the revenue. This revenue sharing often amounts to a per prescription fee paid to the health plan by the PBM. This arrangement occurs in both self-funded and fully insured situations. Regardless of the setting, spread pricing increases the cost of prescription claims above the actual cost paid to the pharmacy.

Health plans often use terms such as “transparency” or “pass-through” to explain pricing, but this does not address the actual issue of spread pricing. Elimination of spread pricing lowers claim costs for patients and plan sponsors, increases the affordability of medications, and is likely to improve overall health outcomes.

Until recently, spread pricing did not affect members of a health benefit plan. When a PBM reported a claim cost of $45, paid the pharmacy $12, and charged the member a $10 co-pay, the member was not affected by the higher claim cost. The plan, however, experienced a charge of $33 more than what was actually paid to the pharmacy. In this type of copayment  design, it’s the plan sponsor (employer) who bears the increased cost of spread pricing. 

Now, with increasing frequency, employers are establishing high deductible health plans (HDHP). An estimated 18 million Americans were covered under this type of plan in 2010*. A HDHP typically has an annual deductible of at least $1,200 for individual coverage and all expenses (except some preventive visits), including pharmacy costs, go toward the deductible. In the most common claim scenario, it’s the prescription drug cost that accumulates to satisfy the member’s deductible and out-of-pocket expenses. In some families, the prescription cost is the primary source of medical care cost, particularly in plans where maintenance check-ups and other wellness services have no co-pay or out-of-pocket exposure.

Spread pricing results in higher consumer costs. It is not unusual for generic prescription charges to be $30-$50 above the actual claim cost.** But more important, may be the affect on compliance and cost of care. While not being specifically studied, it’s reasonable to believe that compliance diminishes as the cost of prescriptions increase by 400% or more. The impact of multiple members of a family, on multiple medications, can be dramatic. The effect of high patient prescription costs on decreased adherence to therapy was the subject of a 2010 Wall Street Journal article.*** Spread pricing was not mentioned as a factor.

If higher medication costs lead to lower compliance, it’s likely to be more significant in patients with multiple or complex disease states. While the extent of lower compliance is variable, higher cost results in lower affordability and is likely to affect disease outcome. This is particularly true in situations where members are paying all of the drug cost, such as in a HDHP.

According to a recent Consumer Reports poll, 48% of adults have taken steps to save money due to the economy. Included among the actions taken were:

• Putting off a doctor’s visit (21%)
• Delaying a medical procedure (17%)
• Taking risks to save on medications (28%), including;
  • Not filling a prescription (16%)
  • Taking an expired medication (13%)
  • Sharing a prescription with someone else (4%).

When one considers that a complex patient with hypertension, hyperlipidemia, and type-2 diabetes can be effectively treated with generic drugs cumulatively costing less than $300 per year, substantial compliance and successful treatment is likely. The likelihood of compliance decreases, however, when spread pricing drives the cost of that same therapy up to $2,000.

Finally, prescription cost increases due to spread pricing, places members and their families above the deductible ceiling quicker. Thus, the cost of therapy impacts the plan sponsor sooner, and negates the fiscal value of a HDHP. While this may not have a direct impact on care, it certainly increases net costs to plan sponsors, in spite of the establishment of a HDHP.

While spread pricing has been a common practice in the PBM marketplace for years, the impact on member costs and member quality of care is now greater. It’s advisable for all plan sponsors to assess the extent of spread pricing that is occurring in their pharmacy benefit and examine methods to eliminate it.

Footnotes

• *American Association of Preferred Provider Organizations. APPO 2010 study of consumer-directed health plans.
• **Based on competitive claim analysis where a transparent PBM has reported actual costs paid to pharmacies. There is no reason to believe that a larger PBM would be paying the pharmacy more than the smaller PBM for which the actual claim price is known.
• *** http://online.wsj.com/article/SB10001424052748703927504575540510224649150.html

About the Authors

Dr. Killilea and Mr. Haas both work in the Portland, OR office of Wells Fargo Insurance Services USA, Inc.  Terrance Killilea, Pharm.D. is Vice President, Integrated Healthcare Metrics -Clinical and Fiscal Integration.  Scott Haas is Vice President, Integrated Healthcare Metrics.

www.Medtipster.com Source: PRNewswire, 9/29/2011, Midwest Business Group on Health (MBGH)

Few employers have a thorough understanding of specialty pharmacy benefits, and only a fraction are of them are aggressively managing what is becoming one of the fastest-growing areas of health care spending, a new survey shows.

A national survey released Sept. 29 by the nonprofit Midwest Business Group on Health in Chicago, one of the nation’s largest business coalitions, found:

Survey Findings

• 70% do not know how much their company was spending on specialty drugs
• 25% of employers have little or no understanding of specialty pharmacy and
• 53% have only a moderate understanding.
• 30% indicated that they did not know how much their total specialty pharmacy claim costs had increased during the past three to five years.

“In addition to the uncertainty and challenges that health reform and the economy are placing on employers, health plans and pharmacy benefit managers, the real driver of drug cost trend growth for employers lies in biologics and specialty pharmacy,” said Cheryl Larson, MBGH Vice President, in a statement. “Our research confirms there is a broad lack of awareness and specific knowledge about benefit design related to specialty pharmacy that illustrates key gaps that need to be addressed.”

The objectives of the survey were to identify and assess the level of knowledge and benefit design gaps of employer plan sponsors in the area of specialty medications and biologic products used to treat conditions such as multiple sclerosis and arthritis. These drugs often require special approvals for their use, instructions on dosing and side effects, and appropriate storage and distribution.

The proportion of employers’ pharmacy benefit expenditures attributable to 

• Specialty drugs grew by 17.4% in 2010, the fastest pace since 2004, according to Medco Health Solutions Inc.’s 2011 Drug Trend Report, which found that
• Specialty drugs represented 16.3% of total health benefit costs.

How survey was conducted

The survey was conducted by MBGH in July 2011 with guidance from Randy Vogenberg, principal at the Institute for Integrated Health Inc., a Baltimore-based consultant that provides integrated pharmaceutical benefits consulting and education to self-insured employers and business coalitions.

Of the 120 employers responding to the survey,

• 69% were self-insured,
• 19% were fully insured, and
• 13% offered a combination of self-insured and fully insured benefit plans.
• Employers responding ranged in size from 500 to 25,000 employees.

About Midwest Business Group on Health (MBGH)

The Chicago based Midwest Business Group on Health (MBGH) was founded in January 1980 by a small group of large Midwest employers to help employers and their population obtain more value from their health care benefit dollars.

www.Medtipster.com Source: Mallory Gillikin, 9/20/2011, www.BusinessInsurance.com

Business Insurance released its ranking of the nation’s largest pharmacy benefit managers. 

1. Medco - Franklin Lakes, N.J.-based firm reported $66 billion in unbundled PBM revenues in 2010, a 10.4% increase from 2009
2. CVS Caremark Corp.  – Woonsocket, R.I.-based firm retained the No. 2 position in the 2011 ranking, reporting $47.8 billion in unbundled PBM revenues in 2010, a 6.4% decrease from 2009.
3. Express Scripts Inc. – Reporting nearly $45 billion in unbundled PBM revenues in 2010, St. Louis-based  firm remained in the No. 3 position in this year’s Business Insurance ranking. Express Scripts, which acquired WellPoint Inc.’s NextRx subsidiaries in December 2009, reported an 81.7% increase in unbundled PBM revenues in 2010.
4.  Prescription Solutions Inc. - Irvine, Calif.-based firm and
5. Catalyst Rx - Rockville, M.D.-based firm rounded out the top five largest PBMs.

To view the full ranking or to purchase copies of the 2011 Directory of Largest Pharmacy Benefit Managers, go to www.BusinessInsurance.com/directories.

www.Medtipster.com Source: Associated Press (AP) – 9.16.2010

Generic medications saved the government and Medicare prescription drug plan beneficiaries about $33 billion in 2007, according to a Congressional Budget Office report.

The report, highlighted on Wednesday by the trade group Pharmaceutical Care Management Association, says an additional $14 billion is expected as first-time generics enter the market through 2012. Medicare Part D is Medicare’s prescription drug program.

“This new research highlights the importance of this proven pharmacy benefit management cost-savings tool,” the Pharmaceutical Care Management Association said in a statement. “Tools pioneered by pharmacy benefit managers, including encouraging the use of generic medications, have lowered costs and expanded access to prescription drugs for seniors in Medicare Part D.”

Pharmaceutical Care Management Association is a trade and lobbying group representing pharmacy benefit managers. During the second-quarter of 2010, the group spent $551,889 lobbying the federal government on issues that affect pharmacy benefit managers, including federal reimbursement on pharmacy payments, rebates, and the regulation of imported prescription drugs. Other issues included lobbying for audit reform on pharmacy benefit managers, according to a filing with the House Clerk’s office on July 20.

Pharmacy benefits managers include Medco Health Solutions Inc., based in Franklin Lakes, N.J., which saw a 14 percent jump in second-quarter profit to $356.9 million on a 10 percent boost in revenue to $16.41 billion. Other pharmacy benefit mangers include Express Scripts Inc., based in St. Louis, which saw second-quarter profit surge 50 percent to $289.9 million on a doubling of revenue to $11.29 billion.

www.Medtipster.com Source: Dow Jones Newswires, By Dinah Wisenberg Brin – 8.11.10

The U.S.’s big pharmacy benefit managers continue to offer clients better deals this year as they compete for business, but they don’t appear to be sliding into a frenzy of unreasonable pricing.

In the current “selling season,” when PBMs look to sign customers for the following year, discounts on new contracts have deepened by one or two percentage points, on average, from a year ago. While PBMs are still lowering their pricing, the pace is slower than a year ago, when PBMs were willing to expand discounts by as much as five percentage points, according to benefit consultants who guide employers on choosing a vendor.

It is unclear how the lower prices will impact margins next year at large PBMs like Medco Health Solutions Inc. (MHS), CVS Caremark Corp. (CVS) and Express Scripts Inc. (ESRX). The increased use of generic drugs, which lowers PBMs’ costs, allows them to be more flexible with prices. That accounts for some of the discount.

The big PBMs have reported lower margins this year, citing a variety of reasons. Medco, though, specifically mentioned lower pricing on renewing contracts, among other items.

PBMs “are taking a little bit of a hit to margin, not much, but they are taking one,” said Michael Jacobs, national clinical practice leader at Xerox Corp.’s (XRX) Buck Consultants. He said the companies have ways of making up elsewhere for client discounts — through greater operating efficiency, cost-shifting to members or raising prices on other drugs.

PBMs handle prescription-drug benefits for employers and health plans, negotiating pricing — including rebates and discounts — with drug makers and pharmacies. They also run their own profitable mail-order pharmacies. The competitive industry has come under increasing pressure to pass along rebates and discounts and improve transparency.

Currently, the industry is engaged in its selling season for 2011 contracts, with billions of dollars in new and renewing business up for grabs or already won.

“Pricing got more competitive this year,” said Kristin Begley, national pharmacy practice leader at benefits consultant Hewitt Associates Inc. (HEW), who didn’t see much switching among her large, national clients, many of which contract with CVS Caremark or Medco.

Rebates got better, and there were “overall better deals across the board,” Begley said. Also, she said, most Hewitt client bids this year required full transparency on pricing structure, with PBMs earning an administrative fee and making money on mail-order while forgoing a margin on drugs dispensed at retail.

PBMs are offering clients better discounts on generic drugs, said David Dross, partner and managed pharmacy practice leader at the Marsh & McLennan Cos. (MMC) Mercer LLC consulting business. Dross added that he has seen some bigger discounts for brand-name drugs as well, although underlying costs on branded drugs generally are increasing.

PBM managements have indicated pricing trends are rational, even though a Sanford C. Bernstein & Co. employer survey earlier this summer suggested a “notable deterioration of the PBM pricing environment,” with more than 40% of respondents noting a decrease in prices.

“Our pricing disciplines have been applied consistently for the past several years as well as going forward to 2011,” Medco spokesman Lowell Weiner said. Medco CEO David Snow Jr., who earlier this year noted instances of aggressive pricing, said last month that he was feeling more comfortable with the competitive marketplace.

Meanwhile, Express Scripts CEO George Paz has said that while “pricing has always been extremely aggressive,” the company uses clinical tools to help drive out costs.

Per Lofberg, who heads CVS Caremark’s PBM operation, recently told analysts that pricing is “intensely competitive like it always … has been, but it’s fundamentally very similar to the past. When plans go out for bid, they are always looking for better economics, and that’s a very important part of the negotiations.”

John Malley, eastern region pharmacy practice leader at Towers Watson & Co. (TW), said PBM pricing isn’t irrational, although it is changing in structure so that players offer better pricing without necessarily losing margin.

“So more simply put, the level of discounts off prescription drugs is not that different between last year and this year, but the overall value of this year’s deals, all in, is better than last year” for the clients, Malley said.

Pricing will become less important a competitive factor as more drugs go generic, Mercer’s Dross predicted. PBMs already are trying to differentiate their clinical offerings, which aim to close gaps in care, customize prescriptions based on genetics and improve compliance to produce better health outcomes and lower costs.

Medtipster Source: CVS Caremark (NYSE: CVS), 10/13/2009, http://info.cvscaremark.com/newsroom

This is an old release from November 2009, BUT I really liked it and have been meaning to post it for some time now.  The message of the CVS Caremark release and the study is: We as an industry need to advise benefit payors to focus on changing consumer utilization behavior rather than  shifting cost. This study took 15,000 people, gave them a $0.00 copay on generic medications. What happened? Overall plan costs decreased due to a GDR (generic dispensing rate) increase and therapy compliance/adherence increased in key classes (antihyperlipidemics, antihypertensives, antidiabetics). WOW…who would have thought that by giving away the cow, you could pay for the milk…

WOONSOCKET, R.I., Oct. 13 /PRNewswire/ — CVS Caremark (NYSE: CVS) presented data at the Academy of Managed Care Pharmacy (AMCP) Annual Educational Conference, which illustrates how innovative pharmacy benefit plan design can impact generic utilization. The study further underscores how pharmacy benefit managers (PBMs) can work with plan sponsors to manage costs and improve health outcomes by working to change plan participant behavior through increased engagement. The study found that implementing a $0 copay structure for generic medications can be an effective strategy to increase generic dispensing, with the generic dispensing rate (GDR) increasing to 60.8 percent (a 4.2 percent increase) during the study period.

“Our 2009 Benefit Planning Survey found that clients are more interested in identifying opportunities to change plan participant behavior, rather than shift costs,” said Jack Bruner, Executive Vice President, CVS Caremark. “The data presented at AMCP illustrates an example of how we can work with our plan sponsors to change and optimize participant behavior in order to achieve increased generic utilization. These types of partnerships enable us to effectively reduce costs for both our client and their plan participants without compromising quality or access.”

In addition to an improvement in GDR during the study period, the analysis found that the average participant cost share for generic medications decreased almost 10 percent (9.4 percent decrease). In addition, the average plan cost per 30 days of therapy also exhibited a slight decline, despite the reduction in generic copayment rates. Prevalence of use in three key preventative drug classes also increased significantly (participants on cholesterol lowering therapy increased 13 percent, on antihypertensive therapy increased seven percent and on diabetic therapy increased nine percent) as a proportion of eligible patients.

“While some plan designs work to drive generic utilization by increasing brand medication copayments, this study demonstrates that lowering the generic copayment can also be an effective strategy to increase GDR,” said Mr. Bruner. “In addition, the data indicates that lowering the generic copayment may also be associated with an increase in participants taking key preventative drugs, which could positively impact adherence and overall health outcomes.”

The study was designed to evaluate the results of plan design changes, including implementation of a $0 copay for generic medications, on the GDR, plan participant cost and impact of plan participant behavior changes on health outcomes. During the study period, participants were allowed to fill prescriptions for generic medications at a preferred retail pharmacy network at a zero dollar copay. The study included 15,000 plan participants covered by a self-funded employer group who were continuously enrolled under the benefit for the duration of the study period (12/1/2007 through 7/31/2009). 

Source: U.S. Department of Labor, 2/2010

The Department of Labor published FAQs to supplement FAQs published in July 2008, and to provide further guidance in response to additional questions from plans and service providers on the requirements for reporting service provider fees and other compensation on the Schedule C of the 2009 Form 5500 Annual Return/Report of Employee Benefit Plan. Inquiries regarding these supplemental FAQs may be directed to EBSA’s Office of Regulations and Interpretations at 202.693.8523.

The new FAQs — numbers 26 and 27 — note that PBMs perform many services for which they are compensated, including services as a third-party administrator, claims processor, and developer of the plan’s formulary and pharmacy network. The FAQs make clear that fees for these services would be reportable as direct compensation on Schedule C.

Q26: Pharmacy Benefit Managers (PBMs) provide services to plans and are compensated for these services in various ways. How should this compensation be reported?

PBMs often act as third party administrators for ERISA plan prescription drug programs and perform many activities to manage their clients’ prescription drug insurance coverage. They are generally engaged to be responsible for processing and paying prescription drug claims. They can also be engaged to develop and maintain the plan’s formulary and assemble networks of retail pharmacies that a plan sponsor’s members can use to fill prescriptions. PBMs receive fees for these services that are reportable compensation for Schedule C purposes. For example, dispensing fees charged by the PBM for each prescription filled by its mail-order pharmacy, specialty pharmacy, or a pharmacy that is a member of the PBM’s retail network and paid with plan assets would be reportable as direct compensation. Likewise, administrative fees paid with plan assets, whether or not reflected as part of the dispensing fee, would be reportable direct compensation on the Schedule C. Payments by the plan or payments by the plan sponsor that are reimbursed by the plan for ancillary administrative services such as recordkeeping, data management and information reporting, formulary management, participant health desk service, benefit education, utilization review, claims adjudication, participant communications, reporting services, website services, prior authorization, clinical programs, pharmacy audits, and other services would also be reportable direct compensation.

Q27: PBMs may receive rebates or discounts from the pharmaceutical manufacturers based on the amount of drugs a PBM purchases or other factors. Do such rebates and discounts need to be reported as indirect compensation on Schedule C?

Because formulary listings will affect a drug’s sales, pharmaceutical manufacturers compete to ensure that their products are included on PBM formularies. For example, PBMs often negotiate discounts and rebates with drug manufacturers based on the drugs bought and sold by PBMs or dispensed under ERISA plans administered by a PBM. These discounts and rebates go under various names, for example, “formulary payments” to obtain formulary status and “market-share payments” to encourage PBMs to dispense particular drugs. The Department is currently considering the extent to which PBM discount and rebate revenue attributable to a PBM’s business with ERISA plans may properly be classified as compensation related to services provided to the plans. Thus, in the absence of further guidance from the Department, discount and rebate revenue received by PBMs from pharmaceutical companies generally do not need to be treated as reportable indirect compensation for Schedule C purposes, even if the discount or rebate may be based in part of the quantity of drugs dispensed under ERISA plans administered by the PBM. If, however, the plan and the PBM agree that such rebates or discounts (or earnings on rebates and discounts held by the PBM) would be used to compensate the PBM for managing the plan’s prescription drug coverage, dispensing prescriptions or other administrative and ancillary services, that revenue would be reportable indirect compensation notwithstanding that the funds were derived from rebates or discounts.

More information to follow via our blog at www.medtipster.com