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Perspectives on Uber’s Partnership With ScriptDrop

May 13, 2021

Uber, seeking to expand its prescription delivery business nationwide, has inked a deal with pharmacy home delivery start-up ScriptDrop that makes Uber the default delivery app for a network of grocery store and independent pharmacies that spans 37 states, AIS Health reported.

The partnership, which is just one of many corporate moves in the pharmacy delivery space, positions Uber to take advantage of the vastly increased consumer demand for home delivery services sparked by the pandemic.

It also puts PBMs in the position of playing some catch-up on developing and promoting home delivery services beyond traditional mail order, says Ashraf Shehata, partner and advisory industry leader for health plans at consulting firm KPMG.

Uber, seeking to expand its prescription delivery business nationwide, has inked a deal with pharmacy home delivery start-up ScriptDrop that makes Uber the default delivery app for a network of grocery store and independent pharmacies that spans 37 states, AIS Health reported.

The partnership, which is just one of many corporate moves in the pharmacy delivery space, positions Uber to take advantage of the vastly increased consumer demand for home delivery services sparked by the pandemic.

It also puts PBMs in the position of playing some catch-up on developing and promoting home delivery services beyond traditional mail order, says Ashraf Shehata, partner and advisory industry leader for health plans at consulting firm KPMG.

The immediate question, he says, is “as we start to see these home delivery options, are we really starting to see the digital world competing against the bricks-and-mortar world, plus delivery? That’s really the dynamic tension here. And I think that there are a lot more chapters to be written in that story.”

But Uber is far from the only company investing in this space, and opportunities for partnerships and acquisitions are plentiful. Meanwhile, PBMs do not appear to be reacting much to the changes in prescription delivery and purchasing patterns, says David Dross, national practice leader for managed care pharmacy consulting at Mercer. “It feels like, at this juncture, PBMs are honestly not seeing enough threat to do something different,” he says.

Competition from Amazon and its subsidiary PillPack hasn’t turned out to be as big of a threat as some in the industry had feared, at least so far, Dross notes. Shehata also doesn’t see Uber and Amazon as immediate threats to PBMs and mail-order pharmacy.

However, Peter Manoogian, principal at the consulting firm ZS Associates, notes that that there are multiple deals that touch on prescription delivery, and PBMs definitely are watching. “I think my clients — PBMs and mail order pharmacies — they are thinking about the threat that an Amazon could bring in the Rx delivery space, because the Amazon delivery model is so intertwined into so many people’s lives,” he says.

by Jane Anderson

 

Radar on Market Access: AllianceRx Walgreens Prime/Highmark Partner to Target SDOH Barriers for People With MS

May 13, 2021

Recently, health insurers have begun focusing on social determinants of health (SDOH) and the role these factors play on health outcomes. Then the COVID-19 pandemic put even more of a spotlight on the issue, disproportionately affecting people of color and low-income communities. Recognizing the impact that SDOH can have, AllianceRx Walgreens Prime is partnering with Highmark Inc. to launch a pilot outreach program focused on the impact of SDOH on people with multiple sclerosis (MS), AIS Health reported.

The program will apply to Highmark members with an MS diagnosis who use AllianceRx Walgreens Prime as their specialty pharmacy. To participate, these members must be willing to take part in a 13-question, voluntary survey conducted via telephone. SDOH-trained nurses from AllianceRx Walgreens Prime are contacting eligible members by phone and offering to administer the survey. Highmark will assess the survey responses to identify how it can design a specific care plan for each member facing SDOH challenges.

Recently, health insurers have begun focusing on social determinants of health (SDOH) and the role these factors play on health outcomes. Then the COVID-19 pandemic put even more of a spotlight on the issue, disproportionately affecting people of color and low-income communities. Recognizing the impact that SDOH can have, AllianceRx Walgreens Prime is partnering with Highmark Inc. to launch a pilot outreach program focused on the impact of SDOH on people with multiple sclerosis (MS), AIS Health reported.

The program will apply to Highmark members with an MS diagnosis who use AllianceRx Walgreens Prime as their specialty pharmacy. To participate, these members must be willing to take part in a 13-question, voluntary survey conducted via telephone. SDOH-trained nurses from AllianceRx Walgreens Prime are contacting eligible members by phone and offering to administer the survey. Highmark will assess the survey responses to identify how it can design a specific care plan for each member facing SDOH challenges.

“Based on the self-identified needs of the member, the Highmark Social Work team will outreach to further assess the SDOH issue or barriers,” explains Amy Shannon, director of health and wellbeing integration at Highmark.

“SDOH can drive up to 80% of an individual’s health outcomes,” she says. “It’s imperative that we assess and provide support to members who are facing SDOH issues.”

According to Rick Miller, BS.Pharm., MS.Pharm., vice president of clinical and professional services at AllianceRx Walgreens Prime, the pilot is focusing on seven domains: “social connections, financial resource strain, health literacy, food insecurity, transportation needs, safety and housing stability. While these SDOH domains may impact any patient with a health condition, in the short time the pilot has been live, we have already identified transportation needs, housing stability and financial resource strain as concerns within the MS population.”

The program will run for one year. Depending on its success, additional patient populations may be included in future phases. “We are exploring a number of specialty disease states for future expansion,” says Miller. “Initial expansion would focus on chronic specialty therapies, as well as specialty disease states, such as oncology and autoimmune diseases, that can be complex and challenging for patients to navigate through the health care system.”

by Angela Maas

 

Radar on Market Access: Medicaid MCOs’1Q Earnings Reflect Revenue Growth

May 11, 2021

As select insurers in recent weeks posted first-quarter 2021 earnings, the positive impact of lower-than-normal utilization, rising COVID-19 vaccination rates and increased Medicaid, Medicare and/or exchange enrollment was slightly tempered by post-pandemic unknowns, especially for those with a heavy Medicaid presence, AIS Health reported.

Centene Corp. on April 27 posted adjusted earnings per share (EPS) of $1.63, up from 86 cents per share in the first quarter of 2020, and revenue of $30 billion, compared with $26 billion a year ago. That 15% increase was due in part to the acquisition of WellCare, which was completed on Jan. 23, 2020, and the ongoing suspension of states’ eligibility redeterminations, which Centene does not expect to resume until at least Aug. 1. Revenue growth, however, was partly offset by an overall drop in exchange membership, state rate and risk-sharing actions, and the repeal of the health insurer fee (HIF) for 2021, explained Executive Vice President and Chief Financial Officer Jeff Schwaneke during an April 27 call to discuss quarterly earnings.

As select insurers in recent weeks posted first-quarter 2021 earnings, the positive impact of lower-than-normal utilization, rising COVID-19 vaccination rates and increased Medicaid, Medicare and/or exchange enrollment was slightly tempered by post-pandemic unknowns, especially for those with a heavy Medicaid presence, AIS Health reported.

Centene Corp. on April 27 posted adjusted earnings per share (EPS) of $1.63, up from 86 cents per share in the first quarter of 2020, and revenue of $30 billion, compared with $26 billion a year ago. That 15% increase was due in part to the acquisition of WellCare, which was completed on Jan. 23, 2020, and the ongoing suspension of states’ eligibility redeterminations, which Centene does not expect to resume until at least Aug. 1. Revenue growth, however, was partly offset by an overall drop in exchange membership, state rate and risk-sharing actions, and the repeal of the health insurer fee (HIF) for 2021, explained Executive Vice President and Chief Financial Officer Jeff Schwaneke during an April 27 call to discuss quarterly earnings.

Centene’s medical loss ratio (MLR) of 86.8% came in higher (worse) than analysts’ expectations but was an improvement over 88.0% reported for the first quarter of 2020.

In an April 27 note to investors, Jefferies analyst David Windley pointed out that Centene’s first quarter results were “disappointing relative to other MCO reports.”

Reporting earnings the next day, Molina Healthcare, Inc. on April 28 beat Wall Street expectations with an adjusted EPS of $4.44 — a 47% increase over the first quarter of 2020 and the highest earnings posted by the five MCOs that had reported at that time. The firm also posted an improved MLR of 86.8% and revenue growth of 43% to $6.5 billion.

Meanwhile, Anthem, Inc. on April 21 posted an MLR of 85.6%, up from 84.2% in the first quarter of 2020 due to COVID-related costs such as testing and vaccine administration and to a lesser extent, the HIF repeal. Adjusted EPS rose 8% from the prior-year quarter to $7.01.

Strong membership growth in the government business was led by Medicaid. When asked about potential changes to Medicaid enrollment going forward, President and CEO Gail Boudreaux during an April 21 call said Anthem expects that reverification will continue to be on hold throughout 2021. Despite its predicted return in 2022, Anthem doesn’t envision a “cliff event” and sees states thinking about “continuing to keep people on the Medicaid rolls,” she said.

by Lauren Flynn Kelly

 

MMIT Reality Check on Narcolepsy (May 2021)

May 7, 2021

According to our recent payer coverage analysis for narcolepsy treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for narcolepsy treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for narcolepsy treatments shows that under the pharmacy benefit, about 54% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In October 2020, the FDA gave another approval to Harmony Biosciences Holdings, Inc.’s Wakix (pitolisant) for the treatment of cataplexy in adults with narcolepsy. The agency initially approved the selective histamine 3 (H3) receptor antagonist/inverse agonist on Aug. 15, 2019.

by Matt Breese

Trends that Matter for Evernorth Drug Trend Report

May 6, 2021

In the 2020 Drug Trend Report recently released by Evernorth, the Cigna Corp. division added yet another chapter to the growing volume of data detailing the profound effects that the COVID-19 pandemic has had on health care, AIS health reported.

On the one hand, the massive amount of deferred routine and elective health care utilization had a dampening effect on the number of new medication users that Evernorth — which houses the PBM Express Scripts — recorded in 2020. New users of asthma/COPD medications dropped the most, by 7.1% year over year, likely reflecting the avoidance of clinical settings among a group that is at particular risk of contracting severe COVID-19.

In the 2020 Drug Trend Report recently released by Evernorth, the Cigna Corp. division added yet another chapter to the growing volume of data detailing the profound effects that the COVID-19 pandemic has had on health care, AIS health reported.

On the one hand, the massive amount of deferred routine and elective health care utilization had a dampening effect on the number of new medication users that Evernorth — which houses the PBM Express Scripts — recorded in 2020. New users of asthma/COPD medications dropped the most, by 7.1% year over year, likely reflecting the avoidance of clinical settings among a group that is at particular risk of contracting severe COVID-19.

Yet for commercial plans managed by Evernorth, the overall drug utilization trend increased by 3.1%, compared with just 1.4% in 2019.

“We saw higher utilization of prescription drugs to treat mental health issues associated with the pandemic — anxiety, insomnia, and depression,” says Evernorth Chief Innovation Officer Glen Stettin, M.D. “Among people with previously diagnosed and common chronic conditions, such as diabetes, high blood pressure and heart disease, many of which are risk factors for hospitalization and death from COVID-19, we also saw an increase in utilization. This utilization was driven by higher medication adherence, itself a result of more people choosing to fill their medication for 90 day vs. 30 day supplies, and the convenience and safety of having their medication delivered to their homes.”

Evernorth’s report also included statistics that are typical of drug trend reports in more normal years. The Cigna division reported 4% total trend across its commercial plans, 3% trend in Medicare, 1.4% in Medicaid and 5.5% in health insurance exchange plans.

by Leslie Small

 

Radar on Market Access: Report Shows Small Share of Drugs Account for Majority of Medicare Spending

May 6, 2021

An April 19 analysis by the Kaiser Family Foundation (KFF) found that a small number of drugs accounted for the majority of drug spending in Medicare, and that negotiating drug prices could lower overall spending in the program, AIS Health reported.

According to the report, the 250 top-selling drugs in Medicare Part D with one manufacturer and no generic or biosimilar competition accounted for 60% of net total Part D spending, while the top 50 drugs covered under Medicare Part B accounted for 80% of total Part B drug spending.

An April 19 analysis by the Kaiser Family Foundation (KFF) found that a small number of drugs accounted for the majority of drug spending in Medicare, and that negotiating drug prices could lower overall spending in the program, AIS Health reported.

According to the report, the 250 top-selling drugs in Medicare Part D with one manufacturer and no generic or biosimilar competition accounted for 60% of net total Part D spending, while the top 50 drugs covered under Medicare Part B accounted for 80% of total Part B drug spending.

While the report concludes that negotiating drug prices could save the public money, there is a potential tradeoff to negotiating all drug prices, report coauthor Juliette Cubanksi, Ph.D., tells AIS Health. Cubanski is deputy director of KFF’s Program on Medicare Policy.

KFF cannot estimate “what the administrative burden would be for HHS in the process of negotiation,” Cubanksi explains, observing that Part D covers about 3,000 drugs, including many generics.
“Negotiating the price of 3,000 prescription drug products is going to be a massive undertaking that for the majority of those products is not likely to get you much savings,” she adds.

“You’re likely getting the most bang for the buck if you focus on drugs that account for a relatively large share of program spending and that don’t have a generic or biosimilar equivalent,” Cubanski says. “If you’ve only got one manufacturer and the price is pretty high, that makes an easier target than inexpensive products with multiple, competing manufacturers.”

However, there are additional considerations to price negotiation. Cubanski says that it’s “entirely possible” that lower prices in Medicare could result in manufacturers ratcheting up prices in the commercial market to offset losses. Cubanski also observes that pharma companies have argued they would not be able to fund as much research and development if their Medicare profits were eroded, though she is not sure that is the case.

“We would not necessarily be able to say ‘there are fewer drugs now than there were five years ago because of the negotiation process,’” she points out.

by Peter Johnson

 

3 Barriers Faced by Patients Needing Innovative Technologies — and How Pharma Can Help: MMIT Meet the Expert Webinar Recap on Access Trends for Innovative Technology

May 5, 2021

On April 27, MMIT held the next installment of its ongoing Meet the Expert webinar series. This session was focused on trends surrounding patient access to innovative technologies like cell and gene therapies, genetic testing and telemedicine. All three of these technologies have seen huge advances in development and availability — and patient access to them is rapidly changing as well, said MMIT’s Fiza Bari, a senior manager of custom market research.

She described a patient named Rose, who has a Diffuse Large B-Cell Lymphoma. Rose is eligible for chimeric antigen receptor (CAR) T-cell gene therapy that will take her own DNA and create a personal treatment that will target her cancer cells. Her family may also wish to pursue genetic testing, while Rose has been taking advantage of telemedicine this past year due to the pandemic. What access challenges does she face?

On April 27, MMIT held the next installment of its ongoing Meet the Expert webinar series. This session was focused on trends surrounding patient access to innovative technologies like cell and gene therapies, genetic testing and telemedicine. All three of these technologies have seen huge advances in development and availability — and patient access to them is rapidly changing as well, said MMIT’s Fiza Bari, a senior manager of custom market research.

She described a patient named Rose, who has a Diffuse Large B-Cell Lymphoma. Rose is eligible for chimeric antigen receptor (CAR) T-cell gene therapy that will take her own DNA and create a personal treatment that will target her cancer cells. Her family may also wish to pursue genetic testing, while Rose has been taking advantage of telemedicine this past year due to the pandemic. What access challenges does she face?

(1) Cell and gene therapies: Cost is a major barrier to accessing these innovative agents, according to MMIT’s quarterly surveys of payers, providers and practice managers, which capture key insights about major trends impacting access. CAR-T therapy is “high cost,” said one large national carrier with 11.9 million lives. It’s less expensive for the “employer and carrier to continue with maintenance drugs given the lack of stability in employment/carrier.” A regional plan cited “accountability for providers, hospitals, and pharma.” It added, “What if the drug doesn’t work?” Those challenges have led payers to establish complex prior authorization requirements, which in turn impacts oncology practices — and leads to a high administrative burden.

Pharma companies can help by negotiating outcomes-based contracts to help mitigate some of the risk for payers, ultimately making the therapies more easily accessible for patients. These companies also can help ease the administrative burden faced by oncologists and practice managers by providing more support and information on the therapies.

(2) Genetic testing: Rose’s family may want to access genetic testing since B-cell lymphoma can be hereditary. However, many payers require prior authorization for these genetic tests because of a lack of perceived utility. One national plan with 3.9 million lives lamented the “lack of documentation [and] off-label use,” while a pharmacy benefit manager (PBM) with 11.1 million lives said the “standard of care [is] not well established and testing centers [are] not easily accessible, expensive.”

How can pharma companies help ease these barriers? MMIT’s research showed that for payers that cover over 90% of lives, positive outcomes data and inclusion of the need for the genetic test in the therapy label are the most influential factors in deciding to cover testing. So by providing payers with information around labelling and outcomes, pharma can help reduce the administrative burden for oncologists and thus improve access for patients.

(3) Telemedicine has become much more widespread as a means of reducing the risk of COVID-19. According to MMIT’s research, all payers reimburse for telemedicine, and most payers will cover these services for all disease states, not just for COVID-19. But while this access likely will continue for conditions such as behavioral health and dermatology in the post-COVID era, payers see less value in providing access to telemedicine related to oncology services. This can impact patients like Rose, who have seen the benefits of fewer physician visits with telemedicine. Manufacturers can help by providing physicians and payers with educational materials and support in order to encourage the use of telemedicine.

For more information about how MMIT’s market research can help you understand payer and provider perceptions, contact us today at busdev@mmitnetwork.com.

To watch a replay of this webinar, visit www.mmitnetwork.com/meet-the-expert-innovative-technology-webinar.

And check out our webinar lineup here. The next session on May 18 is about Predicting Enrollment Changes in the COVID Era.

Radar on Market Access: Centene’s 1Q Shows Contradictory Impact of Pandemic

May 4, 2021

Centene Corp.’s two dominant business lines — managed Medicaid and the Affordable Care Act exchanges — both were sources of significant headwinds and tailwinds in the first quarter of 2021, underscoring the often-contradictory impact of the COVID-19 pandemic on the health insurance sector, AIS Health reported.

On the one hand, Centene acknowledged in its earnings report that it saw higher COVID-19 and traditional utilization in its ACA marketplace business, surprising Jefferies analysts who noted that “those components have tended to move in opposite directions.” Centene also saw its marketplace membership decline year over year by 14%, the analysts noted.

Centene Corp.’s two dominant business lines — managed Medicaid and the Affordable Care Act exchanges — both were sources of significant headwinds and tailwinds in the first quarter of 2021, underscoring the often-contradictory impact of the COVID-19 pandemic on the health insurance sector, AIS Health reported.

On the one hand, Centene acknowledged in its earnings report that it saw higher COVID-19 and traditional utilization in its ACA marketplace business, surprising Jefferies analysts who noted that “those components have tended to move in opposite directions.” Centene also saw its marketplace membership decline year over year by 14%, the analysts noted.

“We knew [Centene’s] relatively higher pricing would create HIX membership pressure…but thought [the insurer’s] decision not to chase price down would help insulate the MLR [medical loss ratio],” analysts David Windley and David Styblo wrote. “Instead, [Centene] has the double whammy of declining membership and margins.”

During the company’s earnings conference call, Centene President, CEO and Chairman Michael Neidorff expressed optimism about the company’s exchange business outlook and defended its decision “not to participate in a price-related race to the bottom with narrow network coverage.” Narrow networks, he argued, “often encourage out-of-network utilization, which tends to be uncontrolled and expensive.”

In general, Centene expects the ongoing special enrollment period and the expanded ACA exchange subsidies put in place by COVID-19 relief legislation to bolster its marketplace business, Neidorff said.

Dichotomies were also evident in Centene’s Medicaid business. Tailwinds that provided forward momentum in that segment include “continued Medicaid membership growth amid suspended eligibility redeterminations,” Neidorff said.

However, the company highlighted state-initiated Medicaid rate adjustments as a headwind, with Neidorff saying Centene anticipates a $550 million revenue hit this year related to such actions.

Overall in the quarter, Centene reported adjusted earnings per share (EPS) of $1.63, beating the Wall Street consensus of $1.50. Its MLR came in slightly higher than Wall Street’s expectations — 86.8% versus 86.3%.

Windley and Styblo were not impressed, suggesting that Centene’s first-quarter results “were disappointing relative to other MCO reports.” But in a note issued after the insurer’s earnings conference call, Oppenheimer’s Michael Wiederhorn wrote that “though Centene’s businesses have generally faced more challenges during the pandemic, we expect net tailwinds for 2022.”

by Leslie Small

 

MMIT Reality Check on Anemia — Chronic Kidney Disease (Apr 2021)

April 30, 2021

According to our recent payer coverage analysis for anemia treatments due to chronic kidney disease, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for anemia treatments due to chronic kidney disease, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for anemia treatments due to chronic kidney disease shows that under the pharmacy benefit, about 39% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: New-to-market products will have to compete with well-established erythropoiesis-stimulating agents and a biosimilar, as well as an IV iron replacement product for people not on dialysis. Products with improved side-effect profiles compared with ESAs will have an advantage.

by Matt Breese

Perspectives on Interoperability Mandate

April 29, 2021

Payers should look at the looming interoperability mandate as a chance to gain a lasting advantage over their competitors, according to two health care information technology (IT) experts.

In a March 26 webinar hosted by America’s Health Insurance Plans (AHIP), IBM Vice President Michael Curry of Watson Health and Jeff Rivkin, research director for payer IT strategies at IDC Insights, said payers should do more than meet the minimum interoperability standards, AIS Health reported.

“It’s just the tip of the iceberg. We’re going to see a lot of data exchanged. And if you don’t have a fairly robust platform to be able to do that, you’re going to hurt next year, too,” Rivkin said.

Payers should look at the looming interoperability mandate as a chance to gain a lasting advantage over their competitors, according to two health care information technology (IT) experts.

In a March 26 webinar hosted by America’s Health Insurance Plans (AHIP), IBM Vice President Michael Curry of Watson Health and Jeff Rivkin, research director for payer IT strategies at IDC Insights, said payers should do more than meet the minimum interoperability standards, AIS Health reported.

“It’s just the tip of the iceberg. We’re going to see a lot of data exchanged. And if you don’t have a fairly robust platform to be able to do that, you’re going to hurt next year, too,” Rivkin said.

Starting July 2021, HHS will require insurers that sell Medicare Advantage, Medicaid and CHIP managed care, and Affordable Care Act exchange plans to launch an application programming interface (API) that will allow patients to access their complete medical and claims history on demand along with a continually updated provider directory. Payers must also make all of their patient and claims data available to other insurers on a payer-to-payer data exchange, which must be in place by January 2022.

Rivkin said insurers should think about the interoperability mandate and the mandate to release pricing information as the same project. Starting on Jan. 1, 2023, health plans must offer members online shopping tools that allow them to see the negotiated rate between their provider and their plan, as well as a personalized estimate of their out-of-pocket cost for 500 of the most shoppable items and services.

“We’re all in the middle of those implementations, but there’s a huge downstream potential for that data,” Curry explained. He says the pandemic-spurred telehealth boom has accelerated changes in consumer expectations.
“The consumer side…has changed a lot in how payers have to think about their relationships with clients,” Curry added. Consumers, he said, now expect accessing health care to be more similar to “buying something on Amazon.”

“Amazon and those like it have raised the bar from the consumerism perspective,” Rivkin said. “Now, you’ve got a significant number of people in the individual market switching because they shop for price. The idea that retail companies have had for years of loyalty and stickiness…is now relevant to health insurance.”

by Peter Johnson