We know more patients than ever are covered by health insurance. We know emerging technologies, consumer demand and economic pressures are shifting healthcare into new models — models that will engage patients and put them back at the center of care. But how much will these forces noticeably change the healthcare landscape this year? PricewaterhouseCoopers' (PwC) Health Research Institute surveyed 1,000 U.S. adults, experts and clients to find out. They took a pulse on the top health industry issues for the coming year and presented their findings in a webinar last Thursday.  Here are the top 10 issues of 2015. 1. Do-it-yourself healthcare. This year, the intersection of consumer desire and technological advancements will put "D.I.Y. healthcare" at the top of the agenda, PwC predicts. Increasingly, consumers are taking charge of more of their own care. Technology companies are ready to help this happen with the development of apps and mobile devices to track health metrics such as vital signs, medication adherence or even urinalysis. Nearly half of physician respondents said they would be comfortable using data from a mobile device to determine if a patient should be seen in person or prescribed medication, and 90 percent felt the apps and mobile devices would be important to their practice in the next five years, according to PwC's HRI. 2. Making the leap from mobile app to medical device. The mhealth app space is getting more and more crowded. The FDA will likely review more mhealth apps this year than ever before. Regulatory approval could give some apps a competitive edge in a crowded sector. The rush of new apps also means consumers will need a way to sort through all the available tools. 3. Balancing privacy and convenience. Approximately five million patients had their personal records compromised from data breaches last summer alone, Mr. Isgur says. These EHRs, which offer personal, medical, financial and insurance information, can go for up to $1,300 on the black market. Yet as healthcare organizations strive to make data private, they must also consider their consumer, who could benefit from convenient data access. The healthcare industry can learn a lot from the financial and retail sectors on how to balance convenience and privacy with data. Collaborations with experts across industries may help healthcare organizations develop better security strategies. 4. High-cost patients spark cost-saving innovations. There is a very, very small percentage of people that cost our health system a lot of money. The sickest 1 percent of patients generates 20 percent of U.S. healthcare spending and dual eligibles are especially costly. We also know there's a laser focus in most healthcare organizations to try to reduce costs. To do that, many organizations are trying to look at those populations and develop innovative care models. This year we will likely see health systems employ a variety of strategies, including delivering care in new settings, through telehealth and retail clinics, high-tech solutions like wearables and apps, and low-tech solutions like making sure diabetic patients have refrigerators to store…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  Note: This document is updated weekly to reflect changing prices and new products. Did you know that pharmacies (and PBMs) often negotiate discounts on prescription drugs which aren't reflected in AWP, WAC or MAC prices? The only way to be sure you're receiving these discounts is to gain access to invoices. How to Determine if Your Company [or Client] is Overpaying 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 5% 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.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine 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. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]  

One of the most powerful middleman industries in the global economy is emerging from more than a half-decade of difficult transition. Drug distributors purchase drugs, often entire lines of drugs, from manufacturers. They warehouse and sell them to retail chains and mail-order, online and specialty pharmacies, as well as to physician offices and clinics. Three companies dominate this key piece of the pharmaceutical supply chain. The largest, San Francisco-based McKesson (MCK ), reported almost $138 billion in fiscal 2014 revenue. The companies earn slim margins from their massive revenue, however. And those thin profits have come under harsh pressure in recent years due to shifting trends in health care. AmerisourceBergen (ABC), McKesson and Cardinal Health (CAH ) have been able to withstand this squeeze largely because they've combined their purchasing power with major pharmacy chains Walgreen Boots Alliance (WBA ), Rite-Aid (RAD ) and CVS Health (CVS). Source:  www.fda.gov The three dominant drug distributors control more than 85% of the market. Their stocks have trended higher the past five years, with AmerisourceBergen up 29%, McKesson up 27% and Cardinal Health ahead 20% the past 12 months. Challenges And Benefits The drug wholesaler-drugstore partnerships unite the two middlemen in the pharmaceutical supply chain. Their common bond is in wanting to defend the spread between the wholesale price the manufacturer charges and the retail price that the insurer lets pharmacies bill patients. That spread can be paper-thin for branded drugs, and often substantially wider for generics. The catalyst for the distributor/pharmacy chain deals: "The payers in the U.S. have been looking at every single option to lower prices," said Vishnu Lekraj, health care service analyst at Morningstar. This price pressure, applied by the pharmacy benefit manager side, leverages the PBMs' market power to control prices on behalf of insurers, Lekraj said. The AmerisourceBergen-Walgreen, Cardinal Health-CVS and McKesson-Rite Aid ventures have each elevated their generics purchasing to $10 billion to $12 billion a year, estimates FBR Capital Markets data. By joining together, drug wholesalers and drugstores can better withstand the profit squeeze and pass most of the pricing pressure onto generic drug manufacturers, Lekraj says. That advantage until recently has remained largely theoretical, although the partnerships have begun to bear fruit. Rite-Aid's latest quarterly results demonstrate the value provided by its deal struck last February to have McKesson purchase its generic drugs and deliver them directly to stores, notes Fein. The pharmacy chain's total inventories were $255 million below year-ago levels in the third quarter, a boon to working capital and profit margins. "If Rite Aid keeps posting such positive results, expect other large pharmacy buyers to give in ... and begin sourcing generics through the large wholesalers," he wrote on his Drug Channels blog. One wrinkle to McKesson's partnership with Rite Aid: the distributor's plans to use its own NorthStar generic manufacturing arm for some generic production, providing more pressure on generic-drug makers to make concessions on price. McKesson suppliesWal-Mart (WMT) with branded drugs, but the retailing giant currently buys its own…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  Note: This document is updated weekly to reflect changing prices and new products. Did you know that pharmacies (and PBMs) often negotiate discounts on prescription drugs which aren't reflected in AWP, WAC or MAC prices? The only way to be sure you're receiving these discounts is to gain access to invoices. How to Determine if Your Company [or Client] is Overpaying 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 5% 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.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine 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. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

My 12-year-old daughter suffers from asthma, so when she left her inhaler at home during a family trip to Nebraska this fall, we had to replace it. I ordered a new inhaler at the local pharmacy and was shocked when the pharmacist told me it would cost $60. The charge was manageable, but the experience opened my eyes to the dangers of monopolies in the pharmaceutical industry. When the pharmacy told me how much the name-brand version of my daughter's albuterol inhaler would cost, I inquired about the generic. I used to work in a traditional retail pharmacy, and remembered being able to obtain the generic version for about $2. The manager informed me that there was no longer a generic albuterol inhaler available. A few years ago, pharmaceutical companies successfully lobbied the Food and Drug Administration ( to ban traditional inhalers over fears that the chlorofluorocarbon (CFC) used as a propellant was harmful to the ozone layer. The patents on those traditional inhalers had expired, so generic versions were readily available. The ban enabled drug makers to use new propellants, which could justify a new patent for the same drug. As a result, the price went from a few dollars per prescription to $60. Source:  www.uspharmacist.com A new report in the New England Journal of Medicine highlights how big the problem of high-cost generic drugs is getting. Generic drugs to treat everything from intestinal parasites to high blood pressure to depression have increased 570 percent, 2,800 percent and 5,200 percent, respectively — sometimes in as little as one year. In 2012, the McKesson Corporation paid out $151 million to 29 states over allegations that the company artificially raised Medicaid drug prices. McKesson is the country's largest drug wholesaler, and it was alleged that they artificially drove up prices on 1,400 drugs from 2001 to 2009. Going forward, it looks as if things will only get worse. Bryan Birch, the chief executive of Truveris, which analyzes prescription drug prices, recently spoke to Medscape Medical News about the "unprecedented levels of generic price increases" over the last two years. "The folks who benefit from it are the manufacturers of generic drugs, the wholesalers in the United States, and the...pharmacy benefits managers," Birch said, adding that the costs are eventually passed on to consumers. When there is a legitimate shortage of generic drugs, the FDA can usually work to expedite companies' ability to produce the drug, or even deal with overseas manufacturers to import more of the drug. Compounding, when a pharmacist creates a customized medication on a case-by-case basis, is another alternative for patients who need drugs that are hard to find commercially. But the FDA cannot do the same with a single manufacturer of a drug, according to the NEJM report. "U.S. antitrust laws protect consumers only from anticompetitive strategies such as price fixing among competitors," the report notes. "Manufacturers of generic drugs that legally obtain a market monopoly are free to unilaterally raise the prices of their products." I'm…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  Note: This document is updated weekly to reflect changing prices and new products. Did you know that pharmacies (and PBMs) often negotiate discounts on prescription drugs which aren't reflected in AWP, WAC or MAC prices? The only way to be sure you're receiving these discounts is to gain access to invoices. How to Determine if Your Company [or Client] is Overpaying 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 5% 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. -- Tip -- Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine 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. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

Click image to enlarge The impact of specialty drugs continues to increase in both drug utilization and spend. In 2012, specialty drug spend accounted for approximately $87 billion, or about 3.1% of national health spend in the United States. In 2020, the forecasted specialty drug spend is expected to be $400 billion, or about 9.1% of national health spend. In addition, within 4 years, analysts predict that 7 of the top 10 drugs in terms of sales will be specialty products.1 Given this expected growth, the specialty drug pipeline will be of particular interest to patients, prescribers, payers, and pharmacies. New specialty drug approvals As of December 3, 2014, FDA had approved 39 new molecular entities and new therapeutic biologics this year. While there is no universal definition of a specialty drug, approximately 19 of this year’s approvals fit commonly used definitions of specialty products (Table 1).6,7 Of these 19, oncology and rare diseases represented the majority of approvals, a trend that is expected to continue through 2015.2 In The Pipeline
 Oncology Looking ahead to the remainder of 2014 and 2015, the pipeline is again forecasted to have the highest number of approvals in oncology, with approximately one dozen expected approvals for a variety of cancers (Table 2).3 Programmed cell death–1 (PD-1) drugs stand out as an especially promising class of therapy. Pembrolizumab (Keytruda—Merck) was the first of this class to earn FDA approval for the treatment of unresectable or metastatic melanoma. Pembrolizumab, along with fellow experimental PD-1 drug nivolumab (Opdivo—Bristol-Myers Squibb), have earned breakthrough designations from FDA and are likely to see success expanding into other indications. Trials are currently under way with PD-1 agents for a number of cancers, including lung, liver, brain, and solid tumors. Other pipeline drugs are in late stages of development for the treatment of breast, melanoma, non–small cell lung, ovarian, and pancreatic cancers, as well as hematologic malignancies such as leukemia and multiple myeloma. Click image to enlarge Hepatitis C Hepatitis C (HCV) continues to have one of the most intriguing pipelines of any disease state. Within the last year, the approvals of sofosbuvir (Sovaldi—Gilead) and simeprevir (Olysio—Janssen) as individual agents have led to major changes in the treatment of HCV. Gilead’s Harvoni, the combination of sofosbuvir and ledipasvir, was approved in October 2014. In addition, sofosbuvir and simeprevir used together was approved in November 2014. Both of these combination therapies show high sustained viral response rates and are interferon-free, oral regimens. Competition should come from the AbbVie “3D” HCV combination therapy composed of ombitasvir, paritaprevir, and ritonavir (Viekirax) used in combination with dasabuvir (Exviera). An FDA decision for this combination is expected by December 22, 2014. In addition, Merck’s HCV combination of MK-5172 and MK-8742 is also showing good effectiveness in clinical trials. Tough competition from fast-paced innovation in the HCV market has taken a toll on other pipeline agents. Faldaprevir, a late-stage drug from Boehringer Ingelheim, was abandoned. Bristol-Myers Squibb’s daclatasvir and asunaprevir, taken together as a two-drug combination therapy, was…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  Note: This document is updated weekly to reflect changing prices and new products. Did you know that pharmacies (and PBMs) often negotiate discounts on prescription drugs which aren't reflected in AWP, WAC or MAC prices? The only way to be sure you're receiving these discounts is to gain access to invoices. How to Determine if Your Company [or Client] is Overpaying 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 5% 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.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine 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. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]