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Radar On Market Access: Express Scripts Reports Record Low Drug Trend Across Commercial Plans in 2018

Posted by Judy Packer Tursman on Feb 19, 2019

For its first annual drug trend report as a part of Cigna Corp., Express Scripts Holding Co. said it had achieved a record low drug trend of 0.4% across its clients' employer-sponsored commercial plans in 2018. Overall, the PBM reported savings of $45 billion for its clients last year, AIS Health reported.

The PBM cited "an unprecedented 0.3% decline" in per-beneficiary drug spending across Medicare plans. Overall, there was a 1.4% decrease in unit cost trend, which allowed clients to absorb a 1.1% increase in utilization, the PBM said. Oncology replaced diabetes as Medicare’s top therapy class by per member per year spend.
 
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Topics: Industry Trends, Market Access, Data & Analytics, Provider, Payer

Trends That Matter for M&A Activity in Specialty Pharmacy and Infusion Therapy Spaces

Posted by Angela Maas on Feb 14, 2019

The specialty pharmacy and infusion therapy spaces have certainly seen their share of merger and acquisition (M&A) activity over the years. Some challenges within those industries may have helped slow down 2018 activity a bit, observes Reg Blackburn, managing director at The Braff Group. And for 2019, we may see more of the same, AIS Health reported.

As far as specialty pharmacy trends in 2018, Blackburn points out that "the largest specialty pharmacies continue to get even larger. Payer- and chain-owned dominate. Most new entity growth is coming from large academic hospitals starting their own specialty pharmacies."
 
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Topics: Specialty, Industry Trends, Product Release, Data & Analytics

Radar On Market Access: Novel Drugs, High Prices, Ways to Manage Them Remain Hot

Posted by Angela Maas on Feb 14, 2019

With the FDA approving multiple novel new therapies over the past couple of years, we should expect to see more of the same moving forward. But that innovation is not cheap, and the pharmaceutical industry likely will continue to offer products at higher price points than ever before, AIS Health reported.

As payers struggle to rein in high specialty drug prices, many have turned to copay accumulator programs, and this trend shows no signs of slowing. "There was an increased focus on copay accumulator programs in 2018," comments Amy Nash, Pharm.D., president of RelianceRx, the specialty pharmacy affiliate of Independent Health. She tells AIS Health she expects to see "further refinement of copay accumulator programs from payers and additional strategies from pharma to prevent them."
 
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Topics: Specialty, Industry Trends, Product Release, Provider, Payer

Radar On Market Access: Part D Rebate Proposal Might Raise Premiums, Reshape PBMs' Business Models

Posted by Leslie Small on Feb 12, 2019

While a new federal proposal to overhaul the prescription drug rebate system may not be a significant threat to major managed care companies' bottom lines, it will likely be disruptive for insurers and PBMs alike, AIS Health reported.

The proposed rule would remove safe-harbor protections under the federal anti-kickback statute for rebates paid by drug manufacturers to PBMs, Part D plans and Medicaid managed care organizations. Instead, it would create two new safe harbors: one for prescription drug discounts offered directly to patients, and one for fixed-fee service arrangements between drug manufacturers and PBMs.
 
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Topics: Industry Trends, Market Access, Provider, Payer

Perspectives on PBMs' Business Model in State Medicaid Programs

Posted by Leslie Small on Feb 7, 2019

As states take a hard look at how they can reduce prescription drug spending in their Medicaid programs, they've put an already heavily scrutinized type of organization in their crosshairs: PBMs, AIS Health reported.

Ohio, for example, is forcing PBMs to abandon their current "spread pricing" models — in which PBMs pocket the difference between the amount they reimburse a pharmacy for a drug and the (usually higher) amount they charge a plan sponsor. Instead, they’ll move to a "pass-through" model, where PBMs will be paid an administrative fee by the Medicaid program and have to pay pharmacists the same amount that they bill the state for drugs, The Columbus Dispatch reported.

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Topics: Industry Trends, Provider, Payer

Radar On Market Access: California Makes Waves With Pharma Benefits, Purchasing Plan

Posted by Leslie Small on Jan 31, 2019

Under the direction of its new governor, Democrat Gavin Newsom, California is planning to take control of the pharmacy benefit for all of the state's Medi-Cal beneficiaries — the vast majority of which currently have that part of their care administered by private insurers and their PBMs, AIS Health reported. What's more, the order directs state agencies to create bulk-purchasing arrangements for high-priority drugs and establish a framework for letting private businesses and insurers join the state’s buying pool.

The idea of the state's Medicaid program shifting to an entirely fee-for-service drug benefits system is already sparking worries about what it will do to PBMs' bottom lines.
 
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Topics: Industry Trends, Market Access, Provider, Payer

Radar On Market Access: 2018 Saw Slowing M&A Activity; Expect More of the Same in ’19

Posted by Angela Maas on Jan 29, 2019

The specialty pharmacy and infusion therapy spaces have certainly seen their share of merger and acquisition (M&A) activity over the years. Some challenges within those industries may have helped slow down 2018 activity a bit, observes Reg Blackburn, managing director at The Braff Group. And for 2019, we may see more of the same, AIS Health reported.

As far as specialty pharmacy trends in 2018, Blackburn points out that "the largest specialty pharmacies continue to get even larger. Payer- and chain-owned dominate. Most new entity growth is coming from large academic hospitals starting their own specialty pharmacies."
 
Read More

Topics: Specialty, Industry Trends, Data & Analytics

Perspectives on New MA Rule That Touches Protected Classes

Posted by Lauren Flynn Kelly on Jan 24, 2019

CMS on Nov. 26, 2018 issued a proposed rule making changes to the Medicare Advantage and Part D programs that would take effect in 2020. Key provisions in CMS’s latest drug pricing rule include a proposal to extend new flexibility to plan sponsors in the area of so-called six "protected" drug classes and the required implementation of a new electronic real-time benefit tool (RTBT), AIS Health reported.

Under CMS's Contract Year 2020 Medicare Advantage and Part D Drug Pricing Proposed Rule, plans would be able to:
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Drug-Pricing Transparency, Vertical PBM Deals Are Top of Mind for Employers in 2019

Posted by Leslie Small on Jan 22, 2019

As they look to win over employer clients this year, PBMs should be prepared to face stiff competition and embrace emerging trends such as value-based formularies and rebate-free models, benefits consultants tell AIS Health.

"I've heard more interest about RFPs and going out, looking for or market-checking vendors than I have in a while — particularly on the PBM side," says Suzanne Taranto, a principal and consulting actuary for Milliman, Inc.

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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Don’t Expect Major Action on Drug Prices in 2019, Experts Say

Posted by Leslie Small on Jan 15, 2019

As 2019 gets under way, public outrage over high prescription drug prices does not appear to have abated, especially in light of recent news reports indicating manufacturers are raising prices on hundreds of drugs this month, AIS Health reported.

Yet there are plenty of reasons why this concern over drug prices might not result in any significant legislative or regulatory action, experts tell AIS Health. And whatever does occur might benefit health plans and PBMs more than challenge them.

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Topics: Specialty, Industry Trends, Provider, Payer