With the huge generic cliff we have just experienced in prescriptions drugs and plans experiencing 80 percent generic drug use, you would think that the days of the double digit increases in the cost of prescription drugs is over. But many experts tell us that we need to brace ourselves for the over 400 bio-technically developed specialty drugs on the market with therapies of over $100,000 a year. So the question for 2014 now becomes: “How can I get my employees or members of my health plan to choose wisely when selecting drugs and get the most out of those drugs with the looming high cost drugs replacing older therapies?”

Until very recently, the cost of the entire prescription drug transaction was hidden from both the employer and employee. In some cases, it still is. For plans under traditional programs with their pharmacy benefit manager (PBM), the pharmacy is reimbursed a lower amount and a higher amount is charged to the plan for the same transaction, with the PBM taking the undisclosed “spread” in the deal as its administration fee. This type of pricing arrangement leaves little for plans trying to create a sense of consumerism, meaning plans that encourage patients to be more responsible consumers of health care dollars through high front-end deductibles or percentage co-insurance. If it is difficult for the employer to know the true cost of a prescription drug, then how should the patient to be expected to know the cost, and then have the means and access to that information allowing better consumerism of prescription drugs?

A new day has dawned. More and more PBMs are being forced to offer transparent and pass-through deals where the pharmacy is reimbursed exactly what the plan sponsor pays and the plan sponsor reimburses the PBM for its services through a reasonable and fully disclosed administration fee. With this new day and new way of doing things, PBMs have now created mobile applications that assist patients in making smart decisions – when and where they need to make them – to be smarter and better consumers.

The new best weapon to control prescription drug spend is sitting in your employees’ pocket or purse: their smartphone. Research reveals members want more savings and better service. In a 2010 survey of 15 health plans conducted by InfoAlchemy, members are confused by how health care is priced, eight of out ten members want mobile health care applications, member engagement through mobile is 400 percent higher than traditional internet applications and lastly, showing local options helps to reduce cost. According to new research from the Pew Research Center’s Internet & American Life Project, 61 percent of Americans own a smartphone. Many still own a regular cellphone with 91 percent of the adult population owning some sort of mobile phone. But the jump in smartphone owners is substantial.

According to Pew’s previous reports, in May 2011, 35 percent of Americans owned smartphones, while in February 2012, 46 percent owned a more powerful phone. The conclusion to draw from this is that from a health care perspective, members need more and more timely information and many of plans’ members own the information gateway in their pocket. Benefit managers’ challenge is to connect the dots – provide members the information that they want and when and where they want the information, all at a low-cost investment. And they can now do so by collecting a simple 10-digit number.

Up to now, PBM mobile apps have been nothing more than what you could obtain over the internet through the PBM’s website. These dinosaurs of mobile apps allowed the member to find a pharmacy or look up the general cost difference between brand and generic alternatives. But since few members drive to the pharmacy with a computer in the car, these simplistic tools did nothing to provide the information when the member needed it.

New apps are now available through some leading-edge PBMs and a stand-alone application that can purchased and layered on to any willing PBM’s program (i.e. transparent program). There are many applications available and this article only highlights three of the many very good options.

One that is really revolutionary is a program called Medvana. Medvana is a free application that allows the patient to “auction” its prescription at point-of-service to provide the lowest cost option compared to the distance the member is willing to go to get the prescription. Pricing under this program is not an estimate. It is a real-time adjudicated price that reflects the contracted rate for that drug at a particular pharmacy. In contrast, other similar programs offer an approximation or “guesstimate” of what the consumer can expect be charged.

When the estimate is lower than the price the pharmacy actually charges the user, it causes confusion and a loss of trust with users. With Medvana, users have high confidence that the price displayed is the price the pharmacy will charge and can push back on the pharmacy with authority if a higher price is presented to them. The program also provides quick access to alternative drugs that might cost less and yet are clinically effective. Users can quickly review the prices of other drugs in the therapeutic category so that the patient can request their doctor switch them to the lowest cost option. The value to plan sponsors, of course, is…to continue reading click here.

By Susan Hayes, Principal, Pharmacy Outcomes Specialists

The New York Times reported that nearly one in five Medicare patients returned to the hospital within 30 days of their initial discharge. In that first month, the patient has to begin a transition back into their regular routine, along with the application of their newly gained post-discharge treatment. These initial 30 days can reflect not only the quality of the care received at the hospital, but also the education provided to the patient in reference to their medication and can greatly affect their recovery.

For the past two years, Mercy Philadelphia Hospital has teamed up with SunRay Drugs, the Philadelphia College of Pharmacy at the University of Sciences, and Keystone First insurance provider, in order to enhance the progression of care from the hospital to home, particularly in the area of medication management so as to prevent hospital readmission.

This bond of organizations not only works together to dissolve the gap between home and the hospital, but also provide an even greater opportunity to further educate the patients enrolled in this program. From this opportunity, a direct correlation has been seen in readmission rates. As the patient’s medication knowledge is increased, their likelihood of being readmitted to the hospital can decrease.

Compliance Packaging:  Integral part of any good MTM program

Patients that are at a higher risk of readmission are identified and offered enrollment in a medication therapy management (MTM) with SunRay Drugs and the University of Sciences. Through these MTMs, clinical pharmacists uncover the patients’ individual drug therapy problems and work to adjust them. Follow-up appointments give the enrollee an opportunity to grasp a clearer concept of their medication, and assist in giving them the information they need in order to stay out of the hospital.

Mercy Philadelphia Hospital’s Director of Care Coordination Austin Reed and Clinical Pharmacy Coordinator Tom Turco are two key players in this initiative. They are aware of how vital the first 30 days of a patient’s discharge can be to a patient’s short and long-term future. The two also know that the involvement of family members often plays a major part in a patient having a smooth recovery process.

“The families are often the caregivers,” says Turco. “They handle affairs, and in some cases, may be more involved in the details of a patient’s medication, than the patients themselves.”

“We have completely changed our care coordination model in order to better suit the needs of patients. In addition to that, we have been working with other hospitals that are using similar systems, in order to increase our system’s efficiency as well, “says Reed.

“It is crucial that they are well-educated on how to manage their medications,” Turco says in reference to high-risk patients, most notably those that take numerous medications, those with difficulty accessing medications, patients with co-morbid conditions, and the elderly.

In these cases, medication compliance is key in a smooth healing process. The obstruction of one’s treatment can result in complications, morbidity, mortality, and increased healthcare costs. Factors such as low literacy or lack of health insurance coverage can be major causes of unsuccessful medication compliance. As a result, a greater chance of readmission may occur.

Mercy Philadelphia Executive Director Susan Cusack believes that with this connection, the level of care provided will reach an even higher level of efficiency. Cusack states that the patients now have more convenient sources in which they can receive their medication, and also meet with pharmacists.

“This partnership with external sources is vital. It demonstrates that here at Mercy Philadelphia Hospital, we care about our patients, not only when they are in our care, but even after their discharge.”

Since starting the program, Mercy Philadelphia Hospital’s 30-day readmission rates have dropped from 13.8-20.5 percent in January 2011 to July 2012, to 12.9-17.7 percent from November 2012 to February 2013. On a steady decline, the goal of the program is to have a readmission rate of less than 15 percent by the end of 2013.

To learn more about Mercy Health System, visit www.mercyhealth.org.

Read the full story:  By Haywood Brewster

Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.

Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list.

Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It’s impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions.

Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 10% or more price differential (paid versus actual cost) we consider this a problem.

Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.

The drug was developed after researchers funded by the National Institutes of Health, identified the genetic defect. The Cystic Fibrosis Foundation gave Vertex and its predecessor company $75 million in research funding, and allowed it access to its therapeutics development network to speed the trials that gained it FDA approval.

The authors say “pharmaceutical companies have an implicit obligation to put patient well-being and resource utilization on an equal footing with return on investment” and “the pharmaceutical industry and its financial backers should seek to consider both financial return and social good, embracing the tenet of social justice.   They also call for transparency in pricing.  To continue reading click here…

Jeff Levin-Scherz is an Assistant Professor at Harvard Medical School and Harvard School of Public Health. He is the Chief Medical Officer at One Medical, an innovative and growing primary care practice currently in San Francisco, New York and Washington DC.

Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.

Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list.

Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It’s impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions.

Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 10% or more price differential (paid versus actual cost) we consider this a problem.

Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.

Include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to see if better pricing is available in the marketplace compared to what the client is currently receiving. 

When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless.

While health plans across the country are preparing for the Oct. 1 open-enrollment launch of publicly funded health insurance exchanges, a separate movement toward private exchanges is taking place that raises some questions about where PBMs ideally fit into these arrangements and how they will profit from them. Walgreen Co. on Sept. 18 joined a growing list of large employers that have opted to move a portion of their insured employees into private exchanges, through which insurers offer a range of health plan options that employees can select.

And while private exchanges have been gaining traction in the last couple of years, the role of pharmacy still appears to be evolving, with some PBMs pursuing carve-out options and others seeking to operate as partners to the health plan participants. A private exchange allows employers to offer more benefit design choices to employees and in some cases set a defined contribution toward coverage. If workers select a more expensive health plan, they pay the difference in premiums. Some private exchanges make available benefit designs from several different insurers. Other private exchanges are operated by a single carrier and only stock that carrier’s plans. Depending on the exchange model, the health plans may be fully insured or self-funded.

“I think we’re seeing a lot of experimentation going on, and I think the PBMs are in a bit of a standoff mode directly with the exchanges because they don’t know quite how to deal with it other than through whatever insurance company is offering that solution out to the exchanges,” observes Brian Bullock, R.Ph., founder and CEO of The Burchfield Group, Inc. “So I think we may see some changes in that landscape over the coming year or two, but my assessment is, because of the way the private exchanges are being assembled, it’s a challenge for the PBMs to figure out where they fit other than through their partner, the insurance company.” Where the PBMs are most likely to participate as traditional carve-out pharmacy benefit providers, he adds, are in situations where the exchange is offering a self-insured solution.

In the case of Walgreens, 160,000 eligible employees will be able to shop for plans offered by up to five carriers in their geographic region through its proprietary “Live Well Benefits Store,” a marketplace that is an outsourced solution through the Aon Hewitt Corporate Health Exchange. According to the press release issued by Walgreens, the new program enables the employer to continue its “value-based pharmacy benefit, which excludes prescriptions from plan deductibles.”

When asked by DBN whether Walgreens would offer a carve-out option administered by its current PBM, Catamaran Corp., Walgreens spokesperson Michael Polzin responded, “I can’t get into many specifics of our arrangement, except to say that we have been able to set up a solution through each of the insurance carriers that allows us to retain the pharmacy benefit design we have today. But I won’t be able to address questions about specific players.” An Aon Hewitt spokesperson says pharmacy benefits are generally provided as a carve-in through the participating health plans in its Corporate Health Exchange.

Catamaran became the default PBM provider for Walgreens when it purchased Catalyst Health Solutions, Inc., which had acquired the Walgreens Health Initiatives PBM business in 2011. Catamaran declined to comment for this story.

Analysts took the news to mean that Catamaran would no longer be providing pharmacy benefits for Walgreens’ covered employees as of Jan. 1, 2014. In an ISI Group LLC research note issued immediately following the Walgreens announcement, Managing Director Michael Cherny observed that while the loss is an “incremental negative” for Catamaran, it presents a minimal financial impact on the PBM. “Given the company’s increased size following the merger with Catalyst, recent business wins, the long-term Cigna agreement, and the Restat deal, the overall impact should be fairly well mitigated,” he assured investors.