International trendsin Pharmaceutical

Benefit Management

PBMI Conference, Phoenix, February 2010

11 August 2010Presented by:

Ilse Steyn

General manager: Business Services

Mediscor PBM

PBMI Conference, 17–19 February 2010

Phoenix, Arizona, USA

The Pharmacy Benefit Management Institute provides research

and education to help health care benefit executives work with

pharmacy benefit managers (PBMs) and other professionals to

design prescription drug benefit programs. PBMI provides a

forum for the industry to exchange ideas and drive marketplace

changes that improve pharmacy benefits and control costs.

Conference highlights

• Healthcare silos

• Aligning medicine benefit strategies with

stakeholders

• Strategies in medicine benefit design

Value-based benefit design

Improve generic utilisation

• Personal health engagement

• Foundation for Managed Care Pharmacy

Emerging Trend Survey

• 2009-2010 Prescription Drug Benefit Cost and

Plan Design Report

Healthcare silos

Collaboration across health care silos

• Main aim to improve health status outcomes

• Different stakeholders with different views of outcomes

• Health care delivery is fragmented – in silos

• Outcomes improved by collaborating across health care silos

• Medical scheme should drive effort for collaboration between different

stakeholders (providers, administrators, PBMs etc.)

• Improve communication

• Can lead to increase or decrease in cost (across all or some silos) in

the process of improving patient outcomes

Collaboration across health care silos

Stakeholder cooperation is necessary to optimize outcomes

Medical scheme

Disease management

Providers

The PBM

Collaboration across health care silos

Medical schemes create multi-disciplinary plans to improve outcomes in asthma

Collaboration across health care silos to improve patient outcomes

Medical schemes, administrators and managed health

care organisations can collaborate and play part in a

wellness and disease management capacity

Identify highest medical cost for scheme and work back

to medicine benefit – investigate for potential areas of

intervention

E.g. Diabetes = reduced risk by 60% by addressing

incorrect regime

Aligning medicine benefit strategies with stakeholders

Aligning medicine benefit management objectives with your medical scheme’s

health care strategy

Presentation by Dave Borden, Principal, Pharmaceutical Strategies Group

Are your stakeholder’s strategies in line with your strategy?

Strategies in medicine benefit

design

Value-based benefit design

What is value-based benefit design? New buzzword

Using incentives in benefits to encourage members to be more value

conscious in their health behaviour and treatment choices

How to reign in health care costs?

• Prevention is the key

• Incentives drive behaviour

• Encourage members to take personal responsibility for their health

Health management versus disease management

Health management is a system of coordinated health care

interventions and communications for populations with conditions in

which patient self-care efforts are significant

Integrating value-based design and disease management with rewards to improve adherence

Coordinated active value-based benefit design with adherence and

employee rewards

Examples of initiatives from employer:

• Healthy meals at all company events

• Fruit provided twice monthly

• Health and wellness education i.e. nutrition and exercise

• Competitions i.e. biggest loser

• Paid time of for routine physicals and lab

• Recognition of employee successes i.e. CEO wellness challenge

Proactive and passive wellness plans

• Different levels of participation requirements

• Failure to complete Proactive requirements results in member being

dropped to the Passive plan

Example: Value-based design

Cover

behaviour

modification,

but not

medication

Based on

class of

medicine

Example: Value-based design

Improve generic utilisation

• Most health plans achieve greater than 60% generic utilisation

• 2009 – estimated $10 billion brand sales to go generic

• Every 1% increase in generic dispensing rate, tend to save health plan 0.5% to 1.5% in total pharmacy spend

• Strategy to increase generic utilisation Zero co-payment on generic alternatives vs. co-

payment on brands RSA – Reference pricing

• Focus on savings opportunities in key therapeutic classes Example

Rosuvastatin

Escitalopram

Dexlansoprazole

Esomeprazole

Levocetirizine

Desloratadine

Comparison of newer “Me too” medicines to therapeutic alternatives

Patient health engagement

Patient health engagement

Multifaceted approach to controlling cost, increasing efficient

utilisation and enhancing the level of patient treatment

• Communication

Letters/printed, electronic, web-based, phone, face-to-face,

sms-reminders

• Education

Disease specific – chronic diseases

Self-treatable diseases

Lifestyle change education

Generic / therapeutic alternatives

Patient health engagement

• Adherence

Counselling on first fill and treatment drop-out

Outreach to prescribers/providers to resolve gaps in

care

• Wellness programs

Incentives / rewards

Strategies to engage patients in health and wellness initiatives

The role of pharmacists: health coach

• Educates participants about disease condition

• Track the participant’s condition

• Track compliance

• Cholesterol tests, blood pressure checks, foot exams,

eye exams, etc.

• Ensure patient confidentiality

Foundation forManaged Care

Pharmacy Emerging Trend

Survey

Foundation for Managed Care Pharmacy Emerging Trend Survey

Feedback from the 4th Annual FMCP (Foundation for

Managed Care Pharmacy) Emerging Trend Survey, 2009

Top five initiative to implement in the next 2 years

1. Specialty formulary management strategies (42%)

New biological medicines

2. ePrescribing (10%)

3. Unique formulary benefit designs – not value-based (9%)

4. Medication Therapy Management (MTM) (9%)

5. Disease management initiatives (8%)

What is used to determine which drugs should be covered under

specialty pharmacy (i.e. Biologicals, oncology, HIV etc.)

1. Cost (87%)

2. Need for DM or case management (67%)

3. Special handling requirements (66%)

4. Need of protocol to manage appropriate use (62%)

5. Type of administration e.g. injectables (61%)

Most popular components of value-based benefit programs

1. Targeted co-pay designs to increase compliance (89%)

2. Formulary designs customised to specific disease states (87%)

3. Assist employers in identifying at-risk employees (80%)

4. Targeted patient education based on risk (78%)

5. Integrated benefit data/analysis for employers (71%)

6. Specific provider network management (44%)

7. Other (7%)

Foundation for Managed Care Pharmacy Emerging Trend Survey

2009-2010 Prescription Drug Benefit Cost and

Plan Design Report

2009-2010 Prescription Drug Benefit Cost and Plan Design Report

• Value-based design

Implemented by 44.7% of plans

Most popular interventions

• Reduced co-pay for selected drug classes (28.6%)

• Incentive to motivate behaviour change (22.7%)

• Formularies

86.9% of formularies implemented have multiple tiers

Closed formularies have almost disappeared

• Courier pharmacy

96.7% of employers offer access to courier pharmacy for

chronic medicines

17.4% are mandatory

84% use retail pharmacy to dispense 60 days’ supply or

more

• Specialty pharmacy

59.9% offer a specialty pharmacy benefit

30% restrict dispensing to specific providers

2009-2010 Prescription Drug Benefit Cost and Plan Design Report

Quote for the day!

You don’t have to be great to start, but you have to start to be great

Zig Ziglar

Questions ?