Radar on Market Access

Radar on Market Access: Insurers Assess Impact of COVID on Seniors’ Mental Health

July 8, 2021

A recent Health Affairs study, “Decline In New Starts Of Psychotropic Medications During The COVID-19 Pandemic,” shows that new starts of antidepressants and anti-anxiety drugs among seniors during the five months between March and August 2020 were well below expected and historical levels, AIS Health reported.

A recent Health Affairs study, “Decline In New Starts Of Psychotropic Medications During The COVID-19 Pandemic,” shows that new starts of antidepressants and anti-anxiety drugs among seniors during the five months between March and August 2020 were well below expected and historical levels, AIS Health reported.

New starts are lower than expected: 

  • Relative to forecasted levels, researchers observed an 18.6% decline in antidepressant new starts for the initial stay-at-home period of mid-March to mid-May, followed by a 1.4% decline from May 15 to Aug. 8, and an overall drop of 8.9%. Changes in new starts of anxiolytics among seniors fell 15.2% below the forecast in the initial period, 1.8% in the three-month period and 7.7% over the five months. Meanwhile, antipsychotic prescriptions in the initial period were 4.3% below expected levels but increased by 3.4% from May 15 to Aug. 8.

Insurers’ Experience:

  • SCAN Health Plan observed about a 10-fold increase in mental health-related telehealth visits during the “peak months” of the pandemic and in the volume of mental health inquiries, according to Chief Medical Officer Romilla Batra, M.D.
  • The insurer shifted to “an all-hands on deck approach” to ensure members had the appropriate support, such as establishing a dedicated resources hotline for members calling in with concerns about mental health and conducting outreach calls to more than 100,000 members to check on their medical and social needs.
  • The insurer expanded existing partnerships with virtual behavioral health providers to increase access to telehealth and telepsychiatry, made changes to its prior authorization policies to allow for more direct access to mental health care, and launched a partnership with PsychHUB.

by Lauren Flynn Kelly

 

Radar on Market Access: Cigna Doubles Down on Incentives to Spur Biosimilar Adoption

July 6, 2021

Cigna Corp. revealed in a recent press release that starting in July, it “will offer all eligible customers the option to receive a one-time $500 debit card for health care services and products if they decide to switch to a biosimilar or another preferred medication.” The insurer also gave preferred status on its formularies to two approved biosimilars for Janssen’s immunosuppressive drug Remicade (infliximab), Avsola and Inflectra, AIS Health reported.

Cigna Corp. revealed in a recent press release that starting in July, it “will offer all eligible customers the option to receive a one-time $500 debit card for health care services and products if they decide to switch to a biosimilar or another preferred medication.” The insurer also gave preferred status on its formularies to two approved biosimilars for Janssen’s immunosuppressive drug Remicade (infliximab), Avsola and Inflectra, AIS Health reported.

Background:

  • The new “Shared Savings Program” comes months after the American Journal of Managed Care obtained a letter sent to providers by the insurer, stating that patients could receive a $500 debit card if they switch from Novartis’ Cosentyx (secukinumab) to Eli Lilly & Co.’s Taltz (ixekizumab) or an older biologic before Aug. 31 and then refill the prescription before Dec. 31.
  • At the time, Taltz was already preferred over Cosentyx on most of Cigna’s 2021 formularies, “so the $500 card program may have been a signal that Cigna didn’t feel that their traditional utilization management tools were as effective at migrating existing patients to a preferred drug when it comes to these chronic drugs,” says Omar Hafez, managing director at Avalere Health.

Expert’s view:

  • According to Hafez, patient preferences as well as “continuity of care/non-medical switching/step therapy laws” are all barriers to moving patients from their existing biologics, “but the $500 card could help convince some patients to switch on their own, partially neutralizing these barriers.”
  • “The fact that Cigna is rolling this out to the infliximabs could be a sign that Cigna was pleased with the results of [the Taltz/Cosentyx] program and is trying to replicate it in a physician administered drug setting,” Hafez says.

by Leslie Small

 

Radar on Market Access: Experts Predict Home Delivery of Rx Drugs Will Increase

July 1, 2021

Mail-order pharmacies garnered a larger-than-ever share of the prescription drug business due to the pandemic, AIS Health reported.

Mail order will increase:

“We’re seeing a steady increase of mail order,” says Brian Anderson, a principal at Milliman Inc. He expects that, in the next few years, delivered medication will account for half of all fills, with at least 20% of total volume originating from mail-order pharmacies.
Anderson says Milliman’s clients have seen mail order grow and remain high. He adds that fills overall are up. In particular, there are notable “increases in mental health categories, [like] antidepressants,” Anderson says.

Mail-order pharmacies garnered a larger-than-ever share of the prescription drug business due to the pandemic, AIS Health reported.

Mail order will increase:

  • “We’re seeing a steady increase of mail order,” says Brian Anderson, a principal at Milliman Inc. He expects that, in the next few years, delivered medication will account for half of all fills, with at least 20% of total volume originating from mail-order pharmacies.
  • Anderson says Milliman’s clients have seen mail order grow and remain high. He adds that fills overall are up. In particular, there are notable “increases in mental health categories, [like] antidepressants,” Anderson says.

Data varies:

  • Steve Johnson, vice president of health outcomes at Blue Cross Blue Shield affiliate-owned PBM Prime Therapeutics, says via email that Prime has seen prescription dispensing return to a pre-pandemic baseline in various categories.
  • “For some of our Rx Collaborative employer clients, mail order utilization has either remained flat or continues to trend slightly downward since 2Q20. On average, our employers are seeing a gradual decrease of 5 percentage points of mail prescriptions since 2Q20,” Chantell Sell Regan, Pharm.D., national pharmacy practice clinical lead at Willis Towers Watson, wrote in an email.

Rethink retail pharmacies:

  • Anderson says that it’s helpful to understand the shift to mail order as a move to home delivery away from a strict retail experience rather than a transition to mail-order pharmacy dispensing. He expects that many fills will still originate in a retail pharmacy but will be delivered after being filled.
  • Ashraf Shehata, national sector lead for life sciences at KPMG, says that PBMs have essentially become mail-order retailers, and need to start thinking in a consumer-centric manner. A challenge for the sector, he explains, “is rationalizing retail versus PBM” operations.

by Peter Johnson

 

Radar on Market Access: Blues-Funded Startup Aims to Boost Value-Based Drug Pacts

June 29, 2021

Five major Blues affiliates — Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of Michigan, Blue Shield of California, Highmark Inc. and Independence Blue Cross — on June 22 launched a startup company, Evio, that aims to “offer innovative medication solutions to patients, providers and customers,” AIS Health reported.

Five major Blues affiliates — Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of Michigan, Blue Shield of California, Highmark Inc. and Independence Blue Cross — on June 22 launched a startup company, Evio, that aims to “offer innovative medication solutions to patients, providers and customers,” AIS Health reported.

Evio’s three chief goals:

  • Continuing “the evolution toward value-based care and enhancing outcomes-based contracting in the pharmacy space, especially on high-cost drugs,”
  • “Using evidence and data from real patient experiences to ensure the right medication gets to every patient, where, when and how they need it,” and
  • “Developing new, and enhancing existing, partnerships that leverage the innovation happening in the pharmacy and broader healthcare, technology, and analytics sectors today — to improve affordability, outcomes, and experience for patients.”

Experts’ views:

  • “Value-based reimbursements for drugs provide a great opportunity to reduce costs,” says Brian Anderson, a principal with Milliman, Inc. However, “these approaches are challenging to set up, monitor and report on. The goal needs to be to eliminate waste in the system and overprescribing. Once these areas are addressed, the key is to incentivize value-based payments for outcomes and care management.”
  • “Part of me says that this is an attempt by the Blue Cross folks to standardize some kind of value-based purchasing arrangement in a way that would work over multiple plans, which probably would make it more effective,” says Jeff Myers, senior vice president of market access and reimbursement strategies with Catalyst Healthcare Consulting, Inc.

Blues plans’ dedication to lower drug costs:

  • The Blue Cross Blue Shield Association and 18 Blues affiliates — including the most recent addition, Anthem, Inc. — have joined Civica Rx, a not-for-profit organization founded by health systems that works to address shortages and price hikes for generic medicines.

by Leslie Small

 

Radar on Market Access: Aduhelm’s Approval May Come at Major Cost to Medicare

June 24, 2021

Marking the first FDA approval of an Alzheimer’s disease treatment in nearly 20 years, the federal agency on June 7 gave accelerated approval to Biogen Inc. and Eisai Co., Ltd.’s Aduhelm (aducanumab-avwa), AIS Health reported.

Marking the first FDA approval of an Alzheimer’s disease treatment in nearly 20 years, the federal agency on June 7 gave accelerated approval to Biogen Inc. and Eisai Co., Ltd.’s Aduhelm (aducanumab-avwa), AIS Health reported.

Controversial approval:

  • Aduhelm’s two Phase III trials showed contradictory results regarding efficacy. Moreover, patients reported temporary swelling in areas of the brain that caused symptoms such as headache, confusion and nausea, and an adverse reaction. The Institute for Clinical and Economic Review in a draft evidence report concluded that the evidence was “insufficient” to determine the net health benefit of Aduhelm.

Medical benefit coverage:

  • Aduhelm is infused once every four weeks and therefore likely to be covered under the medical benefit. Biogen has said it expects about 80% of potential Aduhelm patients to be covered through Medicare Part B, which would easily double the $37 billion Medicare already spends on Part B drugs annually if Biogen’s estimates are correct that roughly 1 to 2 million Americans would qualify for treatment.

Implications for Medicare:

  • “New generations of drugs are increasingly tied to diagnostic monitoring. In this case, patients may be required to undergo Magnetic Resonance Imaging (MRI) to determine disease progression,” observes Jay Jackson, a principal at Avalere Health. And MRI is a currently covered diagnostic for Alzheimer’s patients, he notes. “While most Medicare beneficiaries have some form of secondary insurance…out-of-pocket expenses for both for those patients without such secondary coverage could create barriers to access.”
  • For MCOs, the drug and related imaging presents a “major incremental cost” to Medicare and could trigger the “significant cost” threshold in Medicare, suggested analysts from Evercore ISI in a June 7 research note.
  • Since MA plan bids were due on June 7, it’s too late for Aduhelm’s approval to be factored into their 2022 capitation rates and it’s unclear at this time what CMS will do for the 2023 capitation rates, suggests Brad Piper, a principal and consulting actuary with Milliman.

by Lauren Flynn Kelly

 

Radar on Market Access: Amazon Will Offer Members 6-Month, Discount Generic Rx Drug Fills

June 22, 2021

Amazon.com, Inc. launched a long-anticipated expansion of its pharmacy business on June 8, saying it will allow Prime members to purchase up to six-month supplies of generic prescription drugs for $6. Experts say Amazon is well positioned to claim substantial market share in the growing prescription drug delivery market, which incumbent players have already begun to target, AIS Health reported.

“I love the model,” says Ashraf Shehata, national sector leader for health care and life sciences at KMPG. Shehata expects that Amazon will offer “almost a branded generic, although it’s branded by the distributor, not the manufacturer. I wouldn’t be surprised if we’re going to see an Amazon Basics side of this — they already have a branded category for other commodities that would fit nicely into this.”

Amazon.com, Inc. launched a long-anticipated expansion of its pharmacy business on June 8, saying it will allow Prime members to purchase up to six-month supplies of generic prescription drugs for $6. Experts say Amazon is well positioned to claim substantial market share in the growing prescription drug delivery market, which incumbent players have already begun to target, AIS Health reported.

“I love the model,” says Ashraf Shehata, national sector leader for health care and life sciences at KMPG. Shehata expects that Amazon will offer “almost a branded generic, although it’s branded by the distributor, not the manufacturer. I wouldn’t be surprised if we’re going to see an Amazon Basics side of this — they already have a branded category for other commodities that would fit nicely into this.”

Shehata says the idea of a white-label generic drug line isn’t novel, but Amazon’s unmatched online retail operation gives it meaningful differentiation.

What separates Amazon is “consumer convenience,” he says. Customers are going to be swayed, he predicts, “not only by the branded generics and the pricing, but people like the familiar consumer front end.”

Text on Amazon’s landing page for the expanded service indicates that, while the company will seek to enter pharmacy networks with insurance carriers, the firm will try to bypass them when possible and capture rebate revenue for itself. While the site says that “we work with most insurance plans,” it also says customers can “save by paying with Amazon Prime.” According to a June 8 note by Citi analyst Ralph Giacobbe, Amazon’s Prime prescription drug operation is administered by Inside Rx, a subsidiary of Cigna Corp.’s Evernorth PBM.

Brian Anderson, a principal at Milliman Inc., says that Amazon will be in the pole position as consumers begin to think of online retail as the default space for filling prescriptions, particularly for maintenance medications. He also expects that Amazon pharmacy could increase utilization.

Shehata says that Amazon’s logistics give the company a notable advantage over legacy players. He also predicts that Amazon can “have a much more predictable inventory of these categories of drugs,” since it will have a more centralized pharmacy operation than legacy pharmacies. What’s more, Amazon “knows a lot about the individual [members.]”

by Peter Johnson