Data & Analytics

Radar On Market Access: Centene to Bolster Pharmacy Services with Magellan Deal

January 19, 2021

In addition to creating “one of the nation’s largest behavioral health platforms,” Centene Corp. will add another pharmacy-related asset to its portfolio with its recently announced $2.2 billion proposed purchase of Magellan Health, Inc, AIS Health reported.

The deal, unveiled on Jan. 4, will deliver 2 million PBM members and 16 million medical pharmacy lives to Centene. The transaction creates “additional value across our pharmacy capabilities,” Centene Chief Financial Officer Jeff Schwaneke said during a Jan. 4 conference call. “This is a large and significant market….We have invested in this area in recent years given its attractive growth opportunities, most recently with the addition of PANTHERx.”

In addition to creating “one of the nation’s largest behavioral health platforms,” Centene Corp. will add another pharmacy-related asset to its portfolio with its recently announced $2.2 billion proposed purchase of Magellan Health, Inc, AIS Health reported.

The deal, unveiled on Jan. 4, will deliver 2 million PBM members and 16 million medical pharmacy lives to Centene. The transaction creates “additional value across our pharmacy capabilities,” Centene Chief Financial Officer Jeff Schwaneke said during a Jan. 4 conference call. “This is a large and significant market….We have invested in this area in recent years given its attractive growth opportunities, most recently with the addition of PANTHERx.”

Centene’s purchase of PANTHERx Rare, LLC, a specialty pharmacy company that focuses on orphan drugs and treatments for rare diseases, closed on Dec. 30.

However, when it comes to integrating its new pharmacy-related holdings, Centene may face some challenges.

During the conference call, Bank of America analyst Kevin Fischbeck asked executives whether they’re worried that Magellan Rx Management could lose managed Medicaid business opportunities in states such as California that are carving out their pharmacy benefits, as it will no longer be a “pure-play PBM.” Centene President, Chairman and CEO Michael Neidorff downplayed such concerns, emphasizing that states’ decisions to carve benefits in and out “are cyclical” and that Magellan will still be able to operate independently once under its acquirer’s umbrella.

Yet in a research note to investors sent after the call, Jefferies analysts David Windley and David Styblo warned about the “risk of customer abrasion” once Magellan is no longer truly independent. “That was a selling point [Magellan] made for all three of its businesses, especially the PBM,” they wrote.

Timothy Epple, a principal at Avalere Health, says that given “the differentiation in how states operate formularies and how states regulate pharmacy benefits, I do think the pharmacy piece of Magellan could be more complex” to integrate than its behavioral health business. “Centene is very state-focused, and you’re basically talking about integrating two assets that likely don’t have perfect overlap in terms of where they’re operating,” Epple adds.

Centene and Magellan expect their deal to close in the second half of 2021, pending approval from regulators and Magellan Health’s stockholders, and other customary closing conditions.

Trends That Matter for MCO’s Role in COVID Vaccine Rollout

January 14, 2021

States and the federal government recently began rolling out the COVID-19 vaccine to health care workers across the country. Health plans, particularly those that serve high-risk individuals, may be ideally situated to coordinate care and update members on vaccination opportunities, experts tell AIS Health.

The FDA on Dec. 11 authorized emergency use of the COVID-19 vaccine made by Pfizer Inc. and BioNTech in individuals age 16 and older. Then the agency on Dec. 18 authorized Moderna’s vaccine for emergency use in people 18 years or older.

Health care workers and nursing home residents have been designated by the Centers for Disease Control and Prevention as the first group (phase 1a) to receive the vaccine.

States and the federal government recently began rolling out the COVID-19 vaccine to health care workers across the country. Health plans, particularly those that serve high-risk individuals, may be ideally situated to coordinate care and update members on vaccination opportunities, experts tell AIS Health.

The FDA on Dec. 11 authorized emergency use of the COVID-19 vaccine made by Pfizer Inc. and BioNTech in individuals age 16 and older. Then the agency on Dec. 18 authorized Moderna’s vaccine for emergency use in people 18 years or older.

Health care workers and nursing home residents have been designated by the Centers for Disease Control and Prevention as the first group (phase 1a) to receive the vaccine.

“I think the paradigm of changing tires on a moving bus applies to this venture,” remarks Margaret Murray, CEO of the Association for Community Affiliated Plans (ACAP). “We certainly support the idea of getting the vaccine to front-line health care workers and the very most vulnerable populations, such as nursing home residents, first. So CDC is off to a good start.”

But ACAP, which is composed of 77 not-for-profit safety net health plans covering Medicaid, marketplace and MA enrollees, is concerned about other vulnerable seniors — such as those who are very frail or homebound and likely dual eligible — who are not part of that first round. “We need to think about them in the next wave,” Murray tells AIS Health via email. “We also need to consider how most equitably to distribute the vaccine.”

In a preliminary analysis — or snapshot — of fee-for-service Medicare claims and Medicare Advantage encounter data from Jan. 1 to Sept. 12, 2020, CMS reported 1.19 million COVID-19 cases and 332,672 related hospitalizations among all 62.3 million beneficiaries. That’s a rate of 517 hospitalizations per 100,000 lives. The data puts into stark clarity what is already suspected about the virus: those at the highest risk of developing severe complications are older, lower income, have preexisting conditions and (with the exception of Asian beneficiaries) are more likely to be racial minorities.

Perspectives on New-to-Market Oral Drugs

January 7, 2021

In its latest quarterly Drug Pipeline Insights Report, OptumRx includes a diverse array of medications that the UnitedHealth Group-owned PBM believes are likely to make a market impact when they’re approved by the FDA, AIS Health reported. One interesting trend that applies to three of the five highlighted drugs is the fact that each is the first oral option in its respective category.

While oral medications tend to be thought of as more convenient than injectable or IV-administered therapies, that factor alone may not confer as much of a competitive advantage as one might think, according to one OptumRx executive.

In its latest quarterly Drug Pipeline Insights Report, OptumRx includes a diverse array of medications that the UnitedHealth Group-owned PBM believes are likely to make a market impact when they’re approved by the FDA, AIS Health reported. One interesting trend that applies to three of the five highlighted drugs is the fact that each is the first oral option in its respective category.

While oral medications tend to be thought of as more convenient than injectable or IV-administered therapies, that factor alone may not confer as much of a competitive advantage as one might think, according to one OptumRx executive.

Take roxadustat, which if approved would be the first novel therapy for chronic kidney disease-related anemia since 1989 and would offer an oral alternative to the injectable erythropoiesis-stimulating agents (ESAs) currently being used to treat the condition.

“Dialysis-dependent patients usually get their ESAs administered with dialysis via IV infusion, so the oral alternative in these patients doesn’t provide a convenience benefit necessarily,” says Bill Dreitlein, senior director of pipeline and drug surveillance at OptumRx. “However, there may be alternative benefits around safety.”

Then there’s Orladeyo (berotralstat), BioCryst Pharmaceuticals, Inc.’s treatment for hereditary angioedema (HAE) attacks. When the FDA approved Orladeyo on Dec. 3, it became the first oral plasma kallikrein inhibitor for the prevention of HAE attacks, Dreitlein says.

“The convenience benefit for berotralstat would have been more significant,” he says, but the 2018 approval of approval of Takhzyro, which is subcutaneously administered every two to four weeks and can be self-administered, “diminishes that because it already reduced the number of injections vs. older C1 concentrate products.”

The FDA on Dec. 18 approved relugolix, the first oral GnRH receptor antagonist on the market for advanced prostate cancer.

Relugolix’s oral administration gives it an advantage over Firmagon (degarelix), which requires monthly subcutaneous injections by a health care provider “and hasn’t garnered much commercial success because of the frequent injections and injection site reactions,” Dreitlein says.

The more common GnRH receptor agonists, on the other hand, require intramuscular injections at intervals ranging from one to six months. “Compared to these drugs, relugolix might confer some clinical advantages, but the convenience benefit is reduced because you are replacing an injection given potentially every six months with an oral daily medication,” Dreitlein adds.

Trends That Matter for COVID Vaccine Distribution

December 31, 2020

As details continue to emerge about the availability of COVID-19 vaccines and how they will be administered, the role that payers will play in the process is becoming clearer, AIS Health reported.

It’s imperative for health plans to do two key things at the same time, according to Katherine Dallow, M.D., the vice president of clinical programs and strategy at Blue Cross Blue Shield of Massachusetts. Payers need to help the entities that will be distributing the vaccine to identify the individuals who should be first in line to be vaccinated, and they need to use their resources to help educate the community.

As details continue to emerge about the availability of COVID-19 vaccines and how they will be administered, the role that payers will play in the process is becoming clearer, AIS Health reported.

It’s imperative for health plans to do two key things at the same time, according to Katherine Dallow, M.D., the vice president of clinical programs and strategy at Blue Cross Blue Shield of Massachusetts. Payers need to help the entities that will be distributing the vaccine to identify the individuals who should be first in line to be vaccinated, and they need to use their resources to help educate the community.

“We might be able to put a puzzle together that an individual provider or group may not have,” she said during a Nov. 18 National Institute for Health Care Management (NICHM) Foundation webinar. “Data from many sources should be used to ensure those who are most vulnerable are ID’d per federal and state guidelines. We can see where folks have seen three different doctors, used telehealth and gone to urgent care.”

In addition, health plans are more likely than providers to have better data about whether individuals have received each of their vaccine doses. That’s because states may expand the scope of the type of providers that can administer vaccines in an effort to broaden access.

While multiple vaccines appear ready to come to market, health plans do have some concerns. According to a recent Avalere Health survey of 39 U.S. health plans and one PBM, collectively representing about 48 million covered lives, the effectiveness of vaccines and therapeutics is the top COVID-19 concern for more than 47% of health plans.

Radar On Market Access: PBMs Continue Integration, Face More Regulatory Challenges in 2020

December 29, 2020

In 2020, the PBM industry continued to deepen its integration with other industry players, a trend that experts say is likely to continue in coming years. The PBM space has consolidated to the point that five firms — UnitedHealth Group’s OptumRx, CVS Health Corp.’s Caremark, Cigna Corp.’s Express Scripts, Anthem Inc.’s IngenioRx, Humana Inc.’s Humana Pharmacy Solutions, and the Blue Cross and Blue Shield affiliate-owned Prime Therapeutics LLC — manage the lion’s share of the pharmacy benefits offered to U.S. health plan members.

Beyond their deepening integration with the payers that own them, these firms are working to expand their data and direct-to-consumer operations, AIS Health reported.

In 2020, the PBM industry continued to deepen its integration with other industry players, a trend that experts say is likely to continue in coming years. The PBM space has consolidated to the point that five firms — UnitedHealth Group’s OptumRx, CVS Health Corp.’s Caremark, Cigna Corp.’s Express Scripts, Anthem Inc.’s IngenioRx, Humana Inc.’s Humana Pharmacy Solutions, and the Blue Cross and Blue Shield affiliate-owned Prime Therapeutics LLC — manage the lion’s share of the pharmacy benefits offered to U.S. health plan members.

Beyond their deepening integration with the payers that own them, these firms are working to expand their data and direct-to-consumer operations, AIS Health reported.

Ashraf Shehata, national sector leader for health care and life sciences at KPMG, says that a “back to basics” approach for 2021 will be essential for PBMs, especially as their health plan owners navigate the uncertainty generated by the COVID-19 pandemic. However, he notes that the space is still managing the aftereffects of transactions and is looking for more deal-making opportunities.

In that realm, the long-term integration of Express Scripts into Cigna has generated the most noise. Under Cigna, Express Scripts has deepened a horizontal relationship with Prime Therapeutics.

Meanwhile, in November, Amazon.com Inc. made a big splash by unveiling new pharmacy services, including a prescription-discount service for uninsured individuals that taps into Express Scripts’ price-negotiation powers with manufacturers.

Midwestern supermarket chain Hy-Vee, Inc. also launched a PBM in December, while in March, Costco Wholesale Corp. purchased a minority stake in Navitus Health Solutions, a subsidiary of integrated health system SSM Health.

Shehata says that PBMs’ data expertise will be a key line of business going forward, especially as regulators and the new Democratic administration increase scrutiny on the industry.

He suggests that PBMs could expand beyond the traditional role into something more like a data and analytics clearinghouse for the entire health care industry and PBMs need to be aggressive in delivering value directly to consumers as regulatory scrutiny on the industry increases.

“Big data and [artificial intelligence is] going to sit in kind of the combination of the traditional PBM, …the more traditional health claim, and… detailed EHR data,” Shehata explains. “You’ll start to see a whole generation of organizations also bring in EHR data, because it’s much more accessible now.”

Perspectives on Amazon Pharmacy

December 24, 2020

Amazon.com, Inc. made a splash in the health care world on Nov. 17 when the online retail powerhouse unveiled new pharmacy offerings that aim to disrupt the prescription drug market with increased convenience and savings, AIS Health reported.

In addition to setting up its own online pharmacy, Amazon is partnering with one of the three largest PBMs — Cigna Corp.’s Express Scripts — to offer a prescription-savings benefit that will be available to Amazon Prime members. “It can be used for discounts up to 80% off generic and 40% off brand name medications at over 50,000 participating pharmacies nationwide,” according to a press release.

Amazon.com, Inc. made a splash in the health care world on Nov. 17 when the online retail powerhouse unveiled new pharmacy offerings that aim to disrupt the prescription drug market with increased convenience and savings, AIS Health reported.

In addition to setting up its own online pharmacy, Amazon is partnering with one of the three largest PBMs — Cigna Corp.’s Express Scripts — to offer a prescription-savings benefit that will be available to Amazon Prime members. “It can be used for discounts up to 80% off generic and 40% off brand name medications at over 50,000 participating pharmacies nationwide,” according to a press release.

Notably, Amazon’s new service offers similar functionalities that health insurers, PBMs and major retail pharmacies have included in their prescription-drug shopping tools — but with the twist of making it clear to consumers when it might be cheaper to purchase their drugs without insurance.

To SVB Leerink analyst Stephen Tanal, that constitutes the only notable — and likely minimal — threat to PBMs’ business models.

“The way in which it could be potentially somewhat bad for PBMs is pretty indirect,” says Tanal. “It’s the idea that to the extent that Amazon is now going to be showing every Prime customer two prices for every pharmacy transaction they do with Amazon, it’s really going to highlight the disparities of the cost to you of any given drug if you use insurance or if you choose not to use insurance.”

“What I worry about a little on the margin is, if a lot of people, a lot of the time, for a lot of different drugs start to see that cash pay’s better than insurance, boy, that’s not going to help sentiment and people’s perceptions of insurers and PBMs,” he adds. If that happens, it could increase policymakers’ appetite to regulate PBMs, Tanal points out.

Still, Ashraf Shehata, KPMG’s national sector leader for health care and life sciences, says that payer-owned PBMs have an advantage that Amazon would be hard-pressed to replicate. “The broader value proposition is the drug spend in combination with the total medical spend,” he says, noting that employers, in particular, want to look at the whole picture when trying to keep down costs.