Radar on Market Access

Radar On Market Access: Express Scripts Exec Urges Smarter Treatment of HIV

November 1, 2018

At the annual Medicaid Health Plans of America conference, Express Scripts Holding Co. Senior Vice President and Chief Medical Officer Steve Miller, M.D., had a simple message for health plan leaders: “You have to think long term if you’re going to have better outcomes,” AIS Health reported.

One area in which Medicaid is not heeding that call, Miller said, is how it approaches treating and preventing HIV.

While the number of HIV patients is decreasing,

At the annual Medicaid Health Plans of America conference, Express Scripts Holding Co. Senior Vice President and Chief Medical Officer Steve Miller, M.D., had a simple message for health plan leaders: “You have to think long term if you’re going to have better outcomes,” AIS Health reported.

One area in which Medicaid is not heeding that call, Miller said, is how it approaches treating and preventing HIV.

While the number of HIV patients is decreasing, the amount spent on treating HIV has risen in recent years — and the culprit is rising drug costs, Miller said. Thus, Medicaid programs and plans are often choosing to cover the least expensive medications, which tend to be multi-tablet regimens, rather than pricier single-tablet therapies, he said.

While that approach may cost less in the near term, patients treated this way are less likely to be adherent to their treatment plans than those who get a single-tablet therapy.

According to Miller, that link between medication adherence and simplified treatment regimens is key, as medication non-adherence can lead to complications that ultimately make patients more expensive to treat.

Commercial health plans, which have less of an issue with finances than Medicaid, almost always choose single-tablet regimens for patients, according to Miller. Medicaid beneficiaries with HIV, on the other hand, are getting single-tablet regimens less than 60% of the time.

“So the reality is we’re sub-optimizing that care, and therefore we’re actually going to cost ourselves a lot more in the long run,” he added.

Radar On Market Access: Proposed Part D Change Might Not Be “Catastrophic”

October 30, 2018

If the Trump administration gets its way, Medicare Part D plan sponsors may at some point be on the hook for a greater share of costs once beneficiaries reach the catastrophic phase of coverage for prescription drugs. While America’s Health Insurance Plans (AHIP) is opposed to the idea, experts tell AIS Health that the time may be ripe for such a change.

Beneficiaries enter the catastrophic coverage phase when, as of 2018,

If the Trump administration gets its way, Medicare Part D plan sponsors may at some point be on the hook for a greater share of costs once beneficiaries reach the catastrophic phase of coverage for prescription drugs. While America’s Health Insurance Plans (AHIP) is opposed to the idea, experts tell AIS Health that the time may be ripe for such a change.

Beneficiaries enter the catastrophic coverage phase when, as of 2018, their “true out-of-pocket costs” exceed $5,000. Once in that phase, beneficiaries pay no more than 5% of the total cost for their drugs, while the federal government pays 80% and the Part D plan pays 15%.

In its fiscal year 2019 budget proposal, the Trump administration suggests increasing plans’ share of costs for catastrophic coverage from 15% to 80% and shifting Medicare’s share from 80% to 20%. More recently, CMS Administrator Seema Verma said during an Oct. 18 event that the change is one area in which Part D could be “updated and modernized.”

Sean Creighton, a vice president in Avalere Health’s policy practice, says the change is probably needed because health plans will soon bear very little risk in the upper end of the Part D benefit.

AHIP, however, says it “strongly disagrees with the basic premise of this proposal — that incentives alone will produce such cost reductions.” It argues that “plans are already fully incentivized to negotiate vigorously for lower costs” and “drug companies are incentivized to provide price concessions only when leverage exists.”

Creighton says it is possible that shifting more risk to plans could result in higher premiums. But as long as the beneficiary cost-sharing in the catastrophic phase remains the same, the proposed policy change is likely to be “sort of invisible” to members, he adds.

On the other hand, increasing plans’ risk will likely cause them to step up some of their price-negotiation practices, such as excluding drugs from formularies, changing tier placement of drugs, and using prior authorization and step therapy. “So it may lead to a situation where access to particular drugs may become more restricted as the plans seek to contain costs,” Creighton says.

Radar On Market Access: UnitedHealth Bolsters OptumRx With Genoa Buy

October 23, 2018

UnitedHealth Group’s acquisition of Genoa Healthcare — the fifth largest pharmacy chain in the country — gives OptumRx an edge in a competitive PBM space where companies are racing to innovate, one expert tells AIS Health.

Ashraf Shehata, a principal in KPMG’s health care and life sciences advisory practice, says not only does the purchase add to UnitedHealth’s ever-growing size — “and bigger is always better” — but it also helps give the company a boost in a highly competitive environment where the CVS Health Corp./Aetna Inc.

UnitedHealth Group’s acquisition of Genoa Healthcare — the fifth largest pharmacy chain in the country — gives OptumRx an edge in a competitive PBM space where companies are racing to innovate, one expert tells AIS Health.

Ashraf Shehata, a principal in KPMG’s health care and life sciences advisory practice, says not only does the purchase add to UnitedHealth’s ever-growing size — “and bigger is always better” — but it also helps give the company a boost in a highly competitive environment where the CVS Health Corp./Aetna Inc. and Cigna Corp./Express Scripts Holding Co. deals are changing the game.

More broadly, Shehata says the acquisition allows UnitedHealth to further expand its capabilities beyond the traditional health plan and PBM space.

By focusing on behavioral health care, Genoa Healthcare picked a niche that historically has not been one of the more glamorous — or highly reimbursed — focus areas, he points out. However, “what’s nice is that niche now is becoming quite important,” as the opioid epidemic continues to roil the nation and affect both the commercially and publicly insured. “So I think the time is right….This asset is really something that’s very interesting for really a broad swath of the industry now,” Shehata adds.

Shehata says the purchase of Genoa Healthcare lends itself best to OptumRx defining itself as a payer-owned PBM model, rather than a retail-focused PBM or “the ultimate hybrid” of health plan, retailer and PBM — like what the CVS/Aetna combination will create.

That’s because Genoa will bolster OptumRx’s ability to care for populations with complex health needs, he says, which is a function more often associated with a payer-owned PBM.

“A transaction of this kind is really building on the scale and capabilities of the health plan — the ability to really integrate around care management and medical protocols, I think, is going to be critical,” he adds.

Radar On Market Access: Drug Prices Increases Are Expected to Slow

October 18, 2018

Pharmaceuticals are expected to undergo a 4.92% price increase from 2018 to 2019, according to the recently released July-August 2018 Drug Price Forecast from Vizient. That’s actually a slowing from the 7.61% increase for 2018, AIS Health reported.

The company conducted its analysis using price and volume data from hospital and non-acute facilities participating in its Vizient Pharmacy Program. Among Vizient members, therapeutic classes with the highest spend include many with specialty drugs.

Pharmaceuticals are expected to undergo a 4.92% price increase from 2018 to 2019, according to the recently released July-August 2018 Drug Price Forecast from Vizient. That’s actually a slowing from the 7.61% increase for 2018, AIS Health reported.

The company conducted its analysis using price and volume data from hospital and non-acute facilities participating in its Vizient Pharmacy Program. Among Vizient members, therapeutic classes with the highest spend include many with specialty drugs.

Disease-modifying antirheumatic agents lead the way with an estimated 8.57% increase, followed by the immunomodulatory agents for multiple sclerosis, at 7.33%. According to the report, “Based on the total amount of spend across care environments, the types of molecular entities approved by the FDA, and the investigational products in the development pipeline, it is certain that specialty pharmaceuticals will continue to play an increasingly important role in pharmacy budgeting.”

However, a handful of events have occurred that are helping slow drug price increases, including CMS giving biosimilars a unique reimbursement code and pass-through status, as well as the administration’s initiative to bring down drug prices.

Challenges within the system include the fragility of the pharmaceutical supply chain, which is leading to multiple drug shortages, and novel new medications that launch at very high prices.

Radar On Market Access: Drug Prices Increases Are Expected to Slow

October 18, 2018

Pharmaceuticals are expected to undergo a 4.92% price increase from 2018 to 2019, according to the recently released July-August 2018 Drug Price Forecast from Vizient. That’s actually a slowing from the 7.61% increase for 2018, AIS Health reported.

The company conducted its analysis using price and volume data from hospital and non-acute facilities participating in its Vizient Pharmacy Program. Among Vizient members, therapeutic classes with the highest spend include many with specialty drugs.

Pharmaceuticals are expected to undergo a 4.92% price increase from 2018 to 2019, according to the recently released July-August 2018 Drug Price Forecast from Vizient. That’s actually a slowing from the 7.61% increase for 2018, AIS Health reported.

The company conducted its analysis using price and volume data from hospital and non-acute facilities participating in its Vizient Pharmacy Program. Among Vizient members, therapeutic classes with the highest spend include many with specialty drugs.

Disease-modifying antirheumatic agents lead the way with an estimated 8.57% increase, followed by the immunomodulatory agents for multiple sclerosis, at 7.33%. According to the report, “Based on the total amount of spend across care environments, the types of molecular entities approved by the FDA, and the investigational products in the development pipeline, it is certain that specialty pharmaceuticals will continue to play an increasingly important role in pharmacy budgeting.”

However, a handful of events have occurred that are helping slow drug price increases, including CMS giving biosimilars a unique reimbursement code and pass-through status, as well as the administration’s initiative to bring down drug prices.

Challenges within the system include the fragility of the pharmaceutical supply chain, which is leading to multiple drug shortages, and novel new medications that launch at very high prices.

Radar On Market Access: Opinions Vary on MA Plans’ Use of Step Therapy in Part B

October 16, 2018

While many stakeholders have praised CMS’s move to allow Medicare Advantage (MA) plans to apply step therapy to drugs covered under Part B, others have cautioned that it could result in delays or restrictions in patients accessing much-needed medications, AIS Health reported.

On Aug. 7, CMS issued new guidance allowing MA plans to use step therapy for Part B drugs as of Jan. 1, 2019. The letter also states that those MA plans that also offer prescription drug coverage may use step therapy to have a beneficiary use a drug under Part D before stepping to one under Part B.

While many stakeholders have praised CMS’s move to allow Medicare Advantage (MA) plans to apply step therapy to drugs covered under Part B, others have cautioned that it could result in delays or restrictions in patients accessing much-needed medications, AIS Health reported.

On Aug. 7, CMS issued new guidance allowing MA plans to use step therapy for Part B drugs as of Jan. 1, 2019. The letter also states that those MA plans that also offer prescription drug coverage may use step therapy to have a beneficiary use a drug under Part D before stepping to one under Part B.

Matt Eyles, president and CEO of America’s Health Insurance Plans, praised the administration’s move. He said, “patients and families deserve the prescription drugs they need at a price they can afford. The new CMS policy helps deliver on that promise while also helping to ensure patients continue to have access to safe, effective, and evidence-based care.”

Meanwhile, some groups expressed their concerns. In a letter to HHS Secretary Alex Azar, the American Medical Association said, “The AMA is concerned about the utilization management tools frequently used by PBMs and health plans to control costs, as they often have little clinical basis and can simply be a means of shifting costs in the system. For example, prior authorization and step therapy protocols can create significant barriers for patients by delaying the start or continuation of necessary medical treatment, which can negatively affect patient health outcomes.”

In an Aug. 8 research note, Leerink analysts noted that “pharmaceutical companies could be enticed to offer rebates back to payers and plans in order to gain preferred status at the front of a step-edit or risk losing volume as a second-line or later agent. In turn, these rebates will lower drug costs for Part B MA plans and patients, but also lower pharmaceutical revenues.”