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MMIT Reality Check on Dry Eye (Aug 2019)

August 30, 2019

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

According to our recent payer coverage analysis for dry eye 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 dry eye treatments shows that under the pharmacy benefit, about 40% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: Contracting for preferred formulary status is expected to expand as new agents are approved. Many payers do not allow coverage for compounded products, so Klarity-C may have access issues.

Trends That Matter for Hepatitis C Drugs

August 29, 2019

Beginning last month, Louisiana has been able to treat hundreds of patients who were waiting to receive a pricey cure for hepatitis C thanks to after hammering out an innovative payment model with a drug manufacturer, AIS Health reported.

Beginning last month, Louisiana has been able to treat hundreds of patients who were waiting to receive a pricey cure for hepatitis C thanks to after hammering out an innovative payment model with a drug manufacturer, AIS Health reported.

But the road to get there was long and difficult, according to Rebekah Gee, M.D., secretary of the Louisiana Dept. of Health, who, during a July 22 event hosted by the Brookings Institution, detailed the challenges she faced in trying to get a costly curative therapy to more people while facing down a $2 billion budget deficit. “We were told ‘No’ at least 50 times from a variety of people, whether it was the industry, or policymakers or individuals at the CDC…because it had never been done before,” she said.

Here’s how the “modified subscription model” works: The state pays a fixed amount to Asegua Therapeutics LLC, a subsidiary of Gilead Sciences, Inc., for the authorized generic of Epclusa (sofosbuvir/velpatasvir tablets), up to a set spending cap, and in return gets unlimited access to the therapy for Medicaid beneficiaries.

For states that want to successfully replicate what Louisiana has done, not only do they need a solid partnership with CMS, but they must understand that price is not the only barrier to expanding treatment, said Neeraj Sood, a professor at the University of Southern California, who helped develop the model.

The graphic below show the current market access to hepatitis C drugs across the Medicaid formularies.

Radar On Market Access: Health Insurers Turn to Data Analytics to Combat Fraud, Waste and Abuse

August 29, 2019

According to the National Health Care Anti-Fraud Association, health insurers lose more than $10 billion each year to health care fraud, waste and abuse. And according to experts, while strides have been made in combatting fraud, there is always going to be some new product ripe for fraud, along with the targets that have been around for years.

According to the National Health Care Anti-Fraud Association, health insurers lose more than $10 billion each year to health care fraud, waste and abuse. And according to experts, while strides have been made in combatting fraud, there is always going to be some new product ripe for fraud, along with the targets that have been around for years.

Melissa Jampol, an attorney with Epstein Becker Green and former assistant U.S. attorney, tells AIS Health that “insurers need to stay one step ahead of the trends.” She is a big proponent of data analytics, contending that robust analytics help insurers analyze prepayment claims and audit results, trying to prevent fraud before it happens and catch it after the fact.

Jampol says that opioid use and abuse is still a hot issue. Other targets of health care fraud she sees are telemedicine and durable medical equipment.

Jo-Ellen Abou Nader, vice president of fraud, waste, and abuse and supply chain optimization at Prime Therapeutics LLC, says last year the PBM launched a new data analytics platform to help identify and weed out fraud, waste and abuse.

She adds that “fraud is an evolution.” While health plans are still seeing the same opioid fraud schemes, there are also new schemes trending due to increased access to technology. For example, technology allows fraudulent companies to have more access to patients who don’t have the ability to see a caregiver in person.

Highmark Inc. has also seen a rise in telemedicine schemes involving compounded pain creams. The insurer is combating this type of fraud by identifying large spikes in certain drugs prescribed, says Kurt Spear, vice president of financial investigations and provider review at Highmark. “We can flag those claims, put a stop on them, and do an investigation,” he adds.

Radar On Market Access: Large Employers Are Concerned About Million-Dollar Treatments

August 27, 2019

For large, self-insured U.S. employers, their No. 1 concern related to pharmacy benefits is how to finance treatments that come with seven-figure price tags.

For large, self-insured U.S. employers, their No. 1 concern related to pharmacy benefits is how to finance treatments that come with seven-figure price tags.

That’s one finding of the National Business Group on Health (NBGH) 2020 Large Employers’ Health Care Strategy and Plan Design Survey, AIS Health reported. Among the 147 employer respondents, 86% said they were either concerned or very concerned about “the impact of million-dollar treatments getting approved by the FDA.”

“The pipeline is looming — there are an estimated 14 new therapies in excess of $1 million each that are on the docket for FDA approval in the coming months and years,” Ellen Kelsay, NBGH’s chief strategy officer, said at a press briefing in Washington, D.C.

Nearly a quarter of large employers polled said that as of 2019, they are delaying the inclusion of newly launched treatments from their formulary to enable their PBM or health plan to better determine the treatment’s efficacy and safety, the NBGH survey noted.

Kelsay also highlighted the fact that 46% of employer respondents in the 2020 survey indicated they would consider a role for government in helping to negotiate prices for high-cost therapies.

“I think that’s a reflection of the frustration employers have” with how to finance high-cost treatments, NBGH President and CEO Brian Marcotte said at the briefing. “It’s not a question of are these good therapies. It’s a question of what can society afford — not just what can employers afford.”

When it comes to specialty drug management, the most notable area of growth is in the use of prior authorization (PA) for medications billed under the medical benefit. The share of employers using PA for drugs under the medical benefit rose from 36% in 2019 to 59% in 2020.

MMIT Reality Check on Hemophilia A (Factor VIII) (Aug 2019)

August 23, 2019

According to our recent payer coverage analysis for hemophilia A (factor VIII) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for hemophilia A (factor VIII) 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 hemophilia A (factor VIII) treatments shows that under the pharmacy benefit, about 34% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: PBMs are increasingly focused on offering high-touch condition management services that give them a more active role in patient care. For example, AscellaHealth, LLC harnesses a variety of resources to help better manage treatment for hemophilia.