Managing Drug Costs in Workers Compensation. Artemis Emslie President, mymatrixx

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1 Managing Drug Costs in Workers Compensation Artemis Emslie President, mymatrixx

2 Agenda Industry overview PBM Background Pricing Benchmarks Cost Drivers WC PBM Programs to Manage Costs Monitoring Plan Performance Hot Topics Legislative Update Summary

3 Pharmacy Landscape 2011 Total Rx spend approx. $319 billion. Growth in Dollars = 3.7% Growth in Transactions = less than 1% Moderate growth in dollars due to generics. Brand name losing patents and more generics in market. Other growth factors include: Lack of introduction of new drugs. OTC conversions. 8% 2011 Market Share 92% 3% growth.6% Growth Retail/Mail Non Retail Source IMS

4 Pharmacy Landscape, cont. Market Update Deals ESI Medco SXC HealthTrans and Catalyst (Walgreens) Private Equity PMSI and Progressive ESI MSC Healthplans are spinning off in-house PBM's Impact to Stakeholders Network System integration

5 PBM Background Physician Dispensing Model Revenue Streams - Difference btw Payer contract & Pharmacy contract - Rebates paid to PBM for market share - Clinical programs Manufacturer (Sets AWP) Doctor Managed Care Payer Claimant/ Patient PBM Wholesaler Data Warehouse - MediSpan - First Databank National Drug Code NDC Manufacturer, drug name and quality Pharmacy Network/ Mail Order Optimal Data Exchange - Patient utilization Payer - Physician Report - PPO

6 Pricing Benchmarks Provide a guideline for multiple data points and stakeholders AWP Average Wholesale Price AAC Average Acquisition Cost NADAC National Average Drug Acquisition Cost RSP Retail Survey Price WAC Wholesale Acquisition Cost ASP Average Sale Price Challenges Time needed to adjust processes Maintenance and data Contracts Legislation Business planning - transitions

7 Cost Drivers Increased numbers of prescriptions per claim. Narcotic usage. Increasing wholesale medication costs. Newer, more expensive drugs. Off label use. Continued growth of senior demographic as a percentage of the workforce. Increasing severity of workplace injuries. Long tail of drug coverage in workers compensation. Direct-to-consumer advertising. Physician Dispensing. Drug Testing.

8 WC PBM Programs to Manage Costs Network compliance/network penetration Third Party Billers/Paper Bills Claimant Communication Card Usage Utilization Management (prospective, concurrent and retrospective) Prior Auth Programs Mail Order Data Management Tools Clinical Programs Step Therapy, Physician Outreach Pharmacy Review Formulary Management Generic conversion

9 Monitoring Plan Performance Plan Information Audit contract term Complex plan coverage documentation Actual Rx Claims Data Utilize both paid claim data and copies of invoices. Financial Review Module Review claims for outliers: AWP Discounts Ingredient cost calculations Administration fees Dispensing fees AWP Neutrality Adjustment Applicable state sales taxes State Fee Schedule Plan Benefit Review Module Review claims for errors from incorrect application of plan rules: Injured worker eligibility Drug coverage first fill & injury-specific formularies Pharmacy/injured workers billings High use of controlled substances Review of utilization management Review prior auth process Review for duplicate claims Other customized edits DAW codes Generic efficiency

10 Hot Topics Physician Dispensing Several states are addressing and considering legislation. National Trends in Opioids* Studies have shown narcotic prescriptions are increasing, which may lead to more abuse in workers comp. Doctors may be over treating injured workers with more, and stronger, narcotics than necessary. Compounding** In the next five years, a growing number of doctors and patients will likely turn to compounding pharmacies to prepare medications. Due to growing number of senior citizens who require alternate doses and strengths. Also due to increasing number of mass manufactured drugs in short supply. Bath Salts Synthetic Stimulant Also sold as plant food Banned in several states including FL, AL, GA, TN *May, 2012 National Safety Council s magazine, Safety + Health, article Injured and addicted? **Compounding Pharmacies in the US: Market Research Report, May 2012, IBISWorld.

11 Legislation Update Physician Dispensing In Florida regulators declined, for a third year, to place into law rules and regulations banning the ability to charge the increased price of a repackaged medication. California, South Carolina and Oklahoma have made considerable changes to close the gap. States to soon review this are Illinois and Hawaii. AWP migration California continues to review options for change to AAC or WAC. Most likely to be held up for months if not years due to the large endeavor involved. No standard is being considered nationally.

12 Legislative Update, cont. Risk Evaluation and Mitigation Strategy (REMS) The Food and Drug Administration Amendments Act of 2007 gave FDA the authority to require a REMS from manufacturers to ensure that the benefits of a drug or biological product outweigh its risks. FDA experts indicate extended-release and long-acting opioids are extensively misprescribed, misused and abused, leading to overdoses, addiction and even death in the US. Blueprint for Prescriber Continuing Education Program for extended-release (ER) and long-acting (LA) opioids introduced.

13 Summary Numerous challenges exist to setting Pricing Benchmarks. PBM s challenged with Network Penetration and Clinical Oversight. Success of a PBM = Managing Costs Proactively Key factors to success include Network Pricing Network Compliance Legislation Physician Dispensing Opioids Analyze ongoing performance of PBM to create process and improvements to program Review Plan Information contract terms Utilize Actual Rx Claims Data

14 Questions? Artemis Emslie

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