Life Sciences

Medicare & Reimbursement Advisor Weekly, October 30th, 2009

Medicare & Reimbursement Advisor Weekly, October 30, 2009


Payers may forgo PA restrictions in more collaborative model

Physicians lack pharmacogenomic training

Nebraska P&T lifts fail-first policies

Employer benefit managers Mercer, Gallagher open up about pharmacy benefits, design, and unmet needs


Payers may forgo PA restrictions in more collaborative model

Even if the products you support are orals for cardiovascular conditions, the following may be helpful to give you insight into a plan’s new-age thinking about utilization management.

A flurry of single-source biologics with attractive side effect profiles is expected to enter the cancer care market without competition in the next few years. Requiring prior authorizations on the coming wave of expensive oncology-specific biologics is an option “but not Aetna’s preferred option as it might preclude payers from engaging in relationships with community oncologists, academic centers, hospitals, and cancer centers,” says Aetna’s Ira Klein, MD, medical director of oncology condition analysis. In lieu of a PA, Klein says payers could try a single-specialty arrangement with an oncology provider, or build a private label insurance product in which the plan acts as a third-party administrator. PAs would close the door to these arrangements and stall recent collaboration among oncology groups and payers.

Editor’s note: The complete interview will appear shortly in Oncology Business Review. I’ll forward a link.

Physicians lack pharmacogenomic training

Although 98% of physicians agree that knowing a patient’s genetic profile may help them better prescribe medications, only 10% believe they have adequate training and education to use pharmacogenomic tests. That’s according to a national benchmark survey of more than 10,000 physicians on their acceptance, use, and knowledge of pharmacogenomic testing from Medco Health Solutions and the AMA. Only 26% of physicians have had any type of education in pharmacogenomics. The survey also found that 13% of physicians had ordered or recommended pharmacogenomic testing for their patients in the preceding six months, and more than 26% planned to do so within the next six months. Among total respondents, 10% reported that pharmacogenomic tests had benefited their patients by improving drug effectiveness, and another 10% said their patients benefited from reduced drug toxicity due to testing.

UHC gives free drug compendium access to network doctors

UnitedHealthcare (UHC) is offering in-network physicians and their staff members free access to the National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium. In January 2008, UHC began basing its benefit coverage for chemotherapy drugs used in outpatient settings on the NCCN Drugs and Biologics Compendium. At this time, UHC is the only health insurer that provides an online NCCN Compendium subscription for in-network physicians. “[We’re] constantly looking for ways to enhance the quality of oncology care for our health plan customers, and this is another important step in doing so,” said Lee Newcomer, MD, UHC’s senior vice president, oncology.

Home health: Outcomes and oral medications

Editor’s note: As home health becomes an emerging managed market, occasionally I will address pharmacy issues that might be worth exploring with your payer customers or internally.

There is a Home Health Compare Web site that posts information about two different types of patient outcomes: (1)End-result outcomes, which report a change in the patient’s status between start or resumption of care and discharge. These outcomes include improvement in ambulation, bathing, transferring, dyspnea, oral medication management, pain interfering with activity, urinary incontinence, and surgical wound status. (2) Utilization outcomes report the rates for utilization of healthcare, captured through transfer or discharge assessments.These outcomes include acute care hospitalization, emergent care, emergent care for wound infection or deteriorating wound status, and discharge to the community. An audio conference on home health and evidence-based care was held earlier this fall. For a complimentary copy and to discuss this market, e-mail me at your convenience. My publisher’s home health division, Beacon Health®, conducted the conference (find details at Beacon Health provides pharmaceutical companies and managed care organizations access to its 10,000 home health companies for education, marketing, consulting and research.

Reminder: P&T presentation restrictions

The Idaho Medicaid P&T Committee appreciates scientific data provided by pharmaceutical companies and their scientists. Per new public testimony guidelines adopted by Idaho Medicaid, scientific data to be presented by pharmaceutical companies or their scientists is limited to new information not already available to P&T Committee members through Provider Synergies, LLC, OHSU’s DERP, and/or other standard drug information sources. Those wishing to submit scientific data for consideration must review data already available to the committee. Material submitted for review needs to be limited to what will be presented. Product monographs and dossiers, P&T Committee briefs, extensive bibliographies, or similar inclusions will cause submissions to be rejected and returned.

Massachusetts may restrict site of care access

Massachusetts’ plan to shake up how providers are paid could have a hidden price for patients: Controlling the state’s soaring medical costs, many healthcare leaders believe, may require residents to give up their freedom to go to any hospital and specialist they want. A growing number of hospital officials and physician leaders warn that the new payment system proposed by a state commission would not work without restrictions on where patients receive care. For the full story, visit 10/11/massachusetts_plan_could_limit_patients_hospital_choices/.

Nebraska P&T lifts fail-first policies

Nebraska Medicaid’s P&T reclassified galantamine to preferred among cholinesterease inhibitors, according to its meeting decision September 24. (See table below.) In addition, the committee renamed the antiemetic class so that it could be more specific to the type of antiemetic, such as cannabinoids and NMDA receptor antagonists. The committee also agreed to develop new clinical criteria for non-preferred NMDA receptor antagonist Emend® (aprepitant). Patients will not be required to fail another drug first, the committee ruled. Among bone resorption suppression and related agents, the committee decided that ForteoTM prescriptions did not need to require a fail-first of nasal calcitonin; clinical criteria for Forteo will be developed to reflect this.

Going beyond the contract

Employer benefit managers Mercer, Gallagher open up about pharmacy benefits, design, and unmet needs

Editor’s note: We spoke with employer benefit managers for this story and include two interviews here with Gallagher Benefit Services and Mercer.

Wyndham Hotels had a minus 3% drug spend in 2008, a sharp contrast to most employers who experienced an upward trend closer to plus 5%. Although it’s difficult to pinpoint a single

reason, Wyndham pays for at least two genetic tests (one for Coumadin® and one for tamoxifen) to see whether employees will benefit from those therapies. It also has a high generic fill rate.


This is a good example of how some employers are now being forced to act creatively in managing and preventing illness. “Wyndam is an innovator in that way, the exception,” says Michael Thomas, PharmD, MBA, who oversees clinical pharmacy operations for Gallagher Benefit Services (GBS), one of the leading U.S. employer benefit managers.

David Doss, the head of Mercer’s managed pharmacy practice, says a large technology company has asked the employer benefit manager (EBM) to tie genomics and testing into its health benefit design, so the trend is emerging.


Mercer’s managed pharmacy practice is the largest of its five specialty groups. It features 22 staff members, including eight clinical pharmacists who do nothing but pharmacy consulting. They work primarily with midsize to large private and public employers—mostly self-funded businesses—advising on everything from benefit design to clinical health plan and PBM management, PBM selection, and collective purchasing agreements. Meanwhile, GBS has 84 U.S. offices specializing in healthcare benefits for employers. Thomas’ team reviews employer drug spend, pharmacy plan design, specialty drug use, formularies, out-of-whack trends, and helps employers choose the right PBM and carve out pharmacy benefits.

Thomas spent 11 years running the pharmacy department for a 2-million member plan with $150 million in drug spend. His background as a retail pharmacist, pharmaceutical consultant, and hospital pharmacist led him to Express Scripts®, where he was vice president of clinical pharmacy for eight years before deciding he wanted a challenge: To help employers make rational decisions about benefit design. “I thought it would be too easy to help pharmaceutical companies get their products on formulary,” Thomas says.


Doss says Mercer doesn’t currently rely on clinical monographs or pharmaceutical companies for clinical information. Rather, it looks to an associate professor of medicine at Harvard. “We never work with pharmaceutical account managers, but I could see a fit for them in our DM approach to evidence-based design,” he says. Some of Mercer’s larger public and private employer customers require patients with certain diseases, such as diabetes, to participate actively in a disease management (DM) program to get a lower copay on brands and generics. “Pharma projects would have to be approved here,” Doss says, “but we did propose to help one company build an online evidence-based design tool recently. I’d say the big need is in programs to improve health outcomes, and focused on adherence coaching, since there’s disparity in the quality of this in the market. We’d be open to ideas there, but we’d have to do it so it wouldn’t compromise our objectivity with employers.”

Gallagher’s Thomas used to contract with pharma in the late 1990s, but not anymore. “I know how they contract, but I also believe there’s a conflict, because we deal with PBMs and employers now, so we stopped doing the contracting with manufacturers,” he says. Typical pharmaceutical support that generally could work, however, includes:

Health fairs at employer sites (although Thomas says these are infrequent and difficult to coordinate)

Educational programming for employers

Employer conferences, such as this week’s Corporate Wellness Conference in Los Angeles

Thomas thinks disease state programs have an important place in the medical management of conditions affecting employees, as long as they are provided in the context of education. “There are certainly opportunities around diabetes, especially, and the specialty area for pharmaceutical companies to provide support,” he says.


Two of Mercer’s largest employer customers implemented value-based design earlier this year. To access low copays on brands and generics, the employee must participate actively in the DM program. “The initial results are positive, but we’re in the transition year, so we’ve seen significant uptick in the percent of people enrolled in DM,” Doss reports. They don’t expect to break even in 2009, but the initial cost-avoidance numbers are good. “More people are taking their meds, which is a good thing, if appropriate, so pharmacy spend is up, but we’re seeing lower numbers of ER visits and other resources dropping. We don’t necessarily want to see MD visits go down, though,” Doss says.

On the horizon, Doss sees EBMs playing a greater role in employer productivity studies. “This hasn’t happened yet, but the biggest part of cost avoidance in evidence-based design is presenteeism in the workplace,” he says. The recent wave of interest in value-based insurance design is surprising to Thomas since the concept started around 1999. “I do see the ROI for employers who support a more open design with zero-dollar copays. Pitney Bowes did this 10 years ago, looking at the diabetic population and adherence, and had all brands and generics at a low copay, equally available, and found a four to one return on investment from this approach, compared to the standard, more commercial-oriented design,” he says. This suggests an appetite for appropriate access on tier 1 and 2 to brands that have a value story.

There’s also a slower movement toward the consumer-driven designs. Just 6% of plans do this. Louisiana State University does this, and it’s actually working very well,” Thomas says, “but I’m not sure it has broad applicability until the model is simplified. It’s very confusing for lay people to navigate.”

GBS profile

About 80% of GBS’ customers have less than 1,500 employees, although Thomas works mostly with clients with up to 10,000 employees. GBS serves countless public sector academic institutions, such as school districts, as well as the University of New Mexico, and private employers such as Travelport and Wyndham Hotels. Total lives are in the “mid-millions,” Thomas says, with about 500,000 lives added in the past two years via request for proposals.


Seventy-five percent of the employers GBS deals with want their drugs to be managed to the lowest cost, Thomas says. “The other 25% use clinical programs that may not reduce drug costs to the lowest level, but do provide more value in reducing overall healthcare costs. Drugs are the most cost-effective therapies, but there is still a lot of waste in the system.”

Thomas spends an inordinate amount of time with employers trying to push the latter and get them to understand that the cost of their drug spend is not indicative of the value of their drug spend. “You have to consider downstream costs, but on the flip side, I also tell employers about the incredible waste they have in some drug spend.” Thomas has noticed a real upswing in interest among employers in the pharmacy benefit and a lot of employers with formularies that are promoting drugs people don’t need. “Everyone in the known universe doesn’t need Nexium®, for example, or many of the cholesterol medications. I know there are people genetically disposed to high cholesterol and other conditions, but there are other answers outside of pharmacy we advise employers to look to,” he says.

But the conversation between EBMs and employers is less about generic fill rates and design. Employers aren’t really openly asking for value-based design. “Instead, they just want us to tell them what’s right or wrong,” Thomas says. This is interesting because it suggests that employers are leaning on EBMs to help them develop the right design for their population, and, in some cases, the most ethical design, as is the case with Wyndham Hotels and its decision to cover certain genetic tests and be open to controlling spend in out-of-the-box ways. Controlling specialty spend is the most challenging area. “There’s been some increase in cost share put on the employee, but not to the level I think it would have increased. And one reason is that compliance/adherence would suffer once you reach $150 for copay,” Thomas says.


EBMs we spoke to for this story, including Mercer and GBS, use the P&T Community and the sites for formulary evaluations. “We follow clinical news from all of the major PBMs since we are linked into their clinical research e-mails,” Thomas adds. “We also do our own research if needed.”


“On formularies, we’ll look at them and often tell employers what they’re missing, tell them if there’s too much on the formulary, help them move specialty drugs appropriately to the pharmacy benefit, and definitely focus on these four therapeutic areas: specialty drugs, cardiovascular, diabetes, and asthma,” Thomas says.


GBS conducts comparisons between PBMs to help an employer understand whether switching to a new PBM will cause disruption and where (such as a rise in copays for a particular drug used by many employees). It’s interesting that the level of discussion with some employers often revolves around the PBM process. Two PBMs will bid for an employer contract, one will offer a discount of AWP minus 18%, the other AWP minus 16% (or some other discount off the selling price), and many employers simply want to go with the better discount without understanding that the PBM may have a more expensive formulary or benefit design.