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Challenges and Opportunities for Pharmacy Directors a.k.a. What Keeps Us Awake at Night Michigan Association of Health Plans Summer Conference Carrie Germain, R.Ph. HealthPlus of Michigan Senior Director, Pharmacy Services Chair, MAHP Pharmacy Directors Committee July 15, 2015 Objectives • Specialty Medications • Rising Cost of Drugs • Legislative Initiatives • Focus on Quality • Transitions of Care Specialty Medications • Balancing value and potential for clinical improvement against the cost of specialty medications • Annual impact on prescription expenses • Specialty Medications=1% of claims and 28-30% of expense • Hepatitis C treatments=>9% of expense • Annual specialty drug trend is 18%-22% • Top specialty categories: • Autoimmune, Cancers, Multiple Sclerosis, Hepatitis C, HIV Specialty Medications • 50% of drug pipeline consists of specialty and biologics • By 2018, 50% of prescription expense projected to be specialty meds • By 2020, 50% of the top 50 selling Rx products will be specialty meds • Impact on government programs (Medicare, Medicaid, Exchanges) • Within 10 years, 10 breakthrough drugs predicted to cost $50 billion Specialty Medications • Plans work with specialty pharmacies to implement clinical criteria/protocols; quantity or days supply limits to control waste; lab and efficacy monitoring; medication adherence support • Medical injectables/infusions are increasingly managed by pharmacy management staff • Prior authorizations and site of service optimization can result in savings, convenience and better outcomes (e.g., IVIg, Remicade) Specialty Medications • On the immediate horizon: • PCSK9 Inhibitors • proprotein convertase subtilisin/kexin type 9 inhibitor • Monoclonal antibody • Sub Q every 2-4 weeks • Cholesterol lowering agent may be approved for: • Familial Hypercholesterolemia • Intolerance to statins • Possibly as traditional therapy • • • • LDL lowering-could be as high as 60% Praluent-July 24th and Repatha-August 27th $7000-$12000 per year Future annual US costs estimated at $50B-$200B Rising Cost of Drugs • Generics Prices • Impact of manufacturer consolidation and product line downsizing: • 1000’s of percent increase in 2014 • Tetracycline-7,000%-17,000% • 100’s of percent increase in 2015 • Propranolol- 300%-400% • Brand Prices • Multiple increases per year • e.g., Insulin increased 27% in 2014 • At what point does drug affordability impact treatment adherence and have negative consequences on total healthcare costs? Legislative Initiatives • Biosimilars • Biosimilars=highly similar lower cost versions of innovator products (Follow on Biologics or FOBs) • Interchangeable biologics=biosimilars that meet additional standards for interchangeability • Estimated savings for biosimilars/interchangeable biosimilars, 10-30% • Bills have been passed in 15 states and are pending in four states, including Michigan • Allows pharmacist to substitute an interchangeable biosimilar and notify patient of the substitution. Substitution of biosimilars would require notice to the prescriber before dispensing. Legislative Initiatives • Pharmaceutical Cost Transparency • Requires manufacturers to report costs such as: • • • • • Research and development Purchase of drug patent/drug company, Clinical trials and regulatory costs Profits All marketing costs for higher cost drugs on an annual basis. • Similar legislation has been introduced in other states (e.g., MA, PA, NY, NC, CA) • This is an opportunity to raise public and legislator awareness for the challenges to healthcare related to very high cost products Legislative Initiatives • Maximum Allowable Cost • Passed in 2014; Implemented April 1, 2015 • Plans required to publish process for generic drug MAC pricing questions and reconsideration within defined timeframes • Must provide up to 3 NDCs for manufacturers within the price range from wholesalers who deliver in Michigan Legislative Initiatives • Medication Synchronization • Legislation pending and under comment by MAHP Pharmacy Directors • Heavily supported by pharmacy providers • Requires health plans to allow synchronization of medication regimens without reduction in dispensing fees • MAHP advocating for prior approval by plan for clinical reasons • Auto Refill • MAHP Pharmacy Directors support introduction of legislation that requires patient involvement/permission for auto prescription refill programs for each drug, each time. • Goals of this legislation is to reduce waste and avoid instances where someone picks up a prescription for someone and patient doesn’t need the drugs.(e.g., Insulin, drugs that have been discontinued) Legislative Initiatives • Audit Bill • Any Willing Provider • Pharmacy Benefit Management Legislation Quality Focus • HEDIS and Medicare Stars • Right Drug, Right Time for the Right Person • Focus has been on engaging physicians and members • Opportunities exists to further integrate pharmacy providers in these efforts • Community pharmacists are increasingly aware of the importance of their Star ratings and the impact on network inclusion and in the future, possibly reimbursement • Work with pharmacists to: • • • • • Address adherence issues identify therapy gaps Simplify regimens Reduce medication costs Synchronize refills Transitions of Care • Focus on high risk chronic conditions • CHF, MI, AF, Asthma/COPD, Pulmonary Embolism, Diabetes, etc., • Reduce likelihood of readmission and improve outcomes • 30% of readmissions within one year are due to an adverse drug event • 70% of patients who were hospitalized have at least one actual or potential medication discrepancy at discharge • How do we improve these statistics? Transitions of Care • All stakeholders need consistent and timely access to electronic data • Hospital staff-obtain and record accurate medication reconciliation upon admission • Inpatient pharmacy staff • Physicians (PCP and Specialists) • Health Plan Pharmacist • Community and Specialty Pharmacy Pharmacists • Home Care, Home Infusion and DME providers • Ensure reliable handoffs, accurate and timely documentation and follow up to monitor recommended therapy adherence Transitions of Care • All stakeholders need consistent and timely access to electronic data • Hospital staff-obtain and record accurate medication reconciliation upon admission • Inpatient pharmacy staff • Physicians (PCP and Specialists) • Health Plan Pharmacist • Community and Specialty Pharmacy Pharmacists • Home Care, Home Infusion and DME providers • Ensure reliable handoffs, accurate and timely documentation and follow up to monitor recommended therapy adherence Questions? Carrie Germain, R.Ph. [email protected] 810-230-2299