Reprinted from DRUG BENEFIT NEWS, biweekly news, proven cost management strategies and unique data for health plans, PBMs, pharma companies and employers.
By Lauren Flynn Kelly, Editor
March 1, 2013 Volume 14 Issue 4
As plan sponsors decide between carve-in and carve-out pharmacy benefit approaches for 2014, integrated PBMs like Humana Pharmacy Solutions, the PBM subsidiary of Humana Inc., and OptumRx, the PBM unit of UnitedHealth Group, are pitching patient-centered specialty pharmacy programs as part of their core services. These high-touch solutions rely on the unique ability of health plan-owned PBMs to look across the medical and pharmacy benefit, which industry observers say is quickly becoming a leading differentiating strategy.
“Data integration within health plans is a real opportunity for health plans to differentiate themselves,” observed Kim Staloch, Pharm.D., chief operating officer of Pharmaceutical Strategies Group, during a panel discussion at the 2013 Pharmacy Benefit Management Institute Drug Benefit Conference, held Feb. 18-20 in Las Vegas. “I really think this is their big opportunity to show the market the value that they’ve talked about for so many years of being that integrated vendor, and specialty is the primary reason why that is a more relevant conversation than it’s been in the past.”
“Synchronization,” or the ability to see both sides of the benefit, is the backbone of OptumRx’s strategy as it goes out to potential employer clients this year. “We think synchronizing specialty across the medical and the PBM benefit is one of the things that differentiates us,” asserts Bruce Mead, senior vice president of client relations, growth and marketing, in a DBN interview. “We’ll never be as synchronized with another medical carrier as we are with UnitedHealthcare because we’ve got a common system that feeds real-time data back and forth, as opposed to a monthly or quarterly feed from other medical carriers.”
“Twenty-five years ago, we were born under the PacifiCare umbrella [as Prescription Solutions] and we’ve always been mostly affiliated with health plans. So I think that’s important because half of spending on specialty is in the medical benefit and we’ve always been a part of managing the medical benefit just by virtue of the fact that we’ve been so close to our parent organizations or our sister organizations that are our medical benefit carriers,” adds Kevin Host, Pharm.D., senior vice president of specialty pharmacy. “To this day we have quite a bit of infrastructure that helps manage that 50% of specialty spend that a lot of the traditional PBMs in specialty just haven’t had opportunities to manage in the past.”
Now that the expiration of its contract with Medco Health Solutions, Inc. (now part of Express Scripts Holding Co.) frees OptumRx to partner with other payers, OptumRx is marketing its PBM services to employers on a standalone basis and as part of an integrated offering with UnitedHealthcare.
One of the unique components of the PBM’s specialty offering, says Mead, is that a specialty patient is assigned a clinician who serves as the contact for the patient moving forward, as opposed to a “pooled approach.” When a patient is first diagnosed or joins OptumRx, a patient care coordinator gathers certain logistics and non-clinical aspects of the patient’s care. A designated clinician then engages with that member and spends about an hour during the first interaction to gauge the patient’s mindset about their condition and understand certain aspects of their care, then follows up with that person on a regular basis, especially if they’re noncompliant with their medications, explains Mead.
On top of that standard offering, OptumRx offers 12 clinical management programs (CMPs) that it has been developing and fine-tuning for the last eight or nine years. This initiative relies on a separate clinical team made up pharmacists and nurses who receive specialized training in certain disease states. Members engage with clinicians for about the first six or seven months of their treatment through scheduled consultations, with up to 400 minutes of one-on-one time, explains Host. Those clinicians assess the patient, create an individualized care plan, connect with their doctors and intervene to optimize dosing. Both programs are available as part of the OptumRx specialty pharmacy program and are available at no extra charge to clients, he adds.
“Ultimately, what we’re seeing is that it has a beneficial effect both on outcomes and cost. And cost not just in the pharmacy benefit but in the medical benefit as well,” says Host, pointing to an article published in the July/August 2012 issue of The American Journal of Pharmacy Benefits. In that study, researchers evaluated an oncology CMP initiated for commercial patients whose medical and pharmacy benefits were administered by UnitedHealthcare in 2007. Patients in the specialty pharmacy cohort had a total average cost per patient per year of $84,105, which was 13% lower (about a $13,000 difference) than the per-year costs for those in the retail pharmacy group. Total medical costs, meanwhile, were 25% lower in the specialty pharmacy group, while the number of oral oncology prescriptions dispensed per patient was higher, with a slightly higher overall oral oncology pharmacy cost associated with patients going through the specialty pharmacy.
Humana Employs High-Touch Patient Care
Humana Pharmacy Solutions, which focused heavily on narrow networks and stripped-down formularies in 2012, tells DBN its big selling point for 2013 is going to be around its specialty products and high-touch service model. And while the PBM unit prides itself on being part of a health plan with a trusted name and having the ability to integrate data for medical and pharmacy clients, Humana Pharmacy Solutions is also looking to grow its pharmacy-only business for self-insured clients. Luke Szymanski, market director of sales, says the company’s “sweet spot” is the mid-market space, which includes municipalities, counties, government agencies and hospitals. Moreover, Szymanski reveals that Humana Pharmacy Solutions was recently selected as one of the vendors for the Mercer RxOptions Collaborative.
“We have a really patient-centric model that we feel is unmatched in the industry,” says Szymanski. “Each new member that comes on board is given a nurse care coordinator — the best way to describe it is a coach — that reaches out to the member, performs a clinical assessment, helps them understand what the medication is, why they’re taking it, etc. And we do this at no extra charge; it’s part of our standard core offering. We know that some of our competitors do charge extra for clinical support.”
Humana Facilitates Financial Aid
At the same time, Humana aims to keep patients on their medications by helping them enroll in a patient assistance program (PAP) when needed. Through its RightSource Specialty Pharmacy, Humana alerts financially challenged members that aid is available — whether it’s sponsored by the drug manufacturer or a state or federal agency — and handles all the up-front paperwork. About 50% of its members going through RightSource have some form of assistance, says Szymanski, who clarifies that this is separate from manufacturer-offered drug discount cards, also known as copay coupons.
The specialty pharmacy boasts a 95.4% adherence rate, versus the industry standard of about 92%. “That’s pretty dramatic. A 3.4% difference makes a difference in patient safety, in their health, how their condition progresses or doesn’t progress, so for these members that have this very high-touch care and these nurses and coaches that are assigned to them and work with them and get to know them, it really makes a difference in the patient outcomes,” asserts Anna Theodorou, director of client solutions. The PAP initiative on average saves about $365 per prescription, and is available to any client with members going through RightSource.
Szymanski adds that it’s rare for a PBM to get that involved with patients’ financial aid, “because there’s a lot of cost in the sense of setting up contracts with manufacturers or the agencies that are providing the assistance, so there’s some overhead there that we actually cover.”
When asked if facilitating access to a PAP is part of OptumRx’s model, Host tells DBN the PBM has established partnerships with foundations and other PAP sponsors and will facilitate the application process and ongoing billing of the member cost share to those organizations when requested by clients.
As David Dross, managed pharmacy practice leader at Mercer, begins to guide employer clients through their 2014 requests for proposals, he says he’s not seeing a profound strategic change in the way any of the PBMs are approaching the marketplace. “Express Scripts is talking about a blend of the old ESI and Medco mantras, which is basically behavioral economics and therapeutic resource centers, while OptumRx and the other carrier-based models are really talking more about the integrated model,” he observes (DBN 2/8/13, p. 1).
“I think they’re basically saying, ‘If you give us everything we can manage the patient better,’” he says of the captive PBMs’ sales approach. “And carve-in PBMs do have sort of a distinct advantage when it comes to specialty in the sense that in many situations they have direct business relationships with physicians. CVS Caremark [Corp.] can make a very compelling argument, but the physician can just blow them off when it comes right down to it because there’s no business relationship. That’s not to say that a physician wouldn’t take in information and be appreciative of new information that they didn’t know, but again, when it comes down to it, the PBMs don’t send business or patients or revenue or however you want to slice it to physicians — and carriers do.”
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