The Excelsior Solutions Difference

Transcription

1 The Excelsior Solutions Difference Expert pharmacy benefit management (PBM) consulting team In-house pharmacists, PBM and Medicare Part D experts Former C-level PBM executives averaging 20+ years industry experience each Manage 18 million+ pharmacy lives Provide unbiased, impartial, expert advice Recommend solutions rather than products Acquired by Lockton in 2012 Specialize in working with self-funded employers, health plans, TPAs and other payers to: Optimize PBM arrangements Leverage improved vendor relationships Identify additional opportunities for cost savings Develop strategies in a dynamic marketplace Provide full disclosure on all compensation 1

2 Excelsior Pharmacy Analytics CONTRACT REVIEWS DIAGNOSTIC STUDIES INDEPENDENT AUDITS PBM MARKETING AND RENEWALS Establish clear contractual definitions Structure dollar-fordollar performance guarantees Secure objective audit procedures Define clear algorithms for guarantee and penalty calculations Pricing benchmarks Disease analysis Drug mix analysis and interchange opportunities Contract review Project employer savings if PBMs were shopped today Brand vs. generic classification Narcotic abuse Independent annual auditing of contractual guarantees Based on all information affecting employer cost (discounts, dispensing fees, rebates, admin fees, brand vs. generic classification, formulary lists, drug mix management) Employers receive penalty check if guarantees were not met Ensure members are not being overcharged Objective approach with transparency and no carrier/pbm-specific incentives Rigorous financial valuation of all proposals Clinical program evaluation Winning PBM must submit to certain contract provisions, guarantees, and annual independent audits 2

3 Full Service Pharmacy Consulting Creating Better Economics Full Market Evaluation Assess current contract > Renegotiate Moving into years 4 and 5 with Premera RFP that includes top PBM s > Leverage health plan pricing Transparent contract > Insure terms and conditions drive most favorable results for client Allow collectives to participate Trend Management RX Mart: Data Analytics Excelsior s proprietary data solution Holds PBM accountable to contract Provides in depth utilization review Drill down capabilities for each client's specific needs Clinical Oversight Pharmacist review of data to determine most effective PBM programs, i.e. Step Therapy, QL, PA Narrow network evaluation Specialty Rx consulting Execution Ongoing Account Management Implementation oversight Quarterly review meetings Plan design benchmarking and consulting Insuring PBM delivers on operational and service commitments 3

4 RxMart Reporting Holding your PBM accountable How is your PBM performing? 4

5 Pharmacy Analytics YOUR MOST HIGHLY UTILIZED HEALTHCARE BENEFIT: PRESCRIPTION DRUGS Detailed Claims Analysis Financial Guarantees Contract Optimization Plan Design Strategies Formulary Management Specialty-Drug Management Medication Adherence Improvement Network and Channel Optimization Contract Reviews Diagnostic Studies PBM Procurement and Renewals Independent Pricing Audits Specialty Drug Strategy BILLIONS Are Wasted on drug choices 5

6 The Financial Significance of Specialty Pharmacy 1% of members = 25 30% of pharmacy spend 53% of specialty paid under medical benefit, managing cost requires site of care strategies 6 Medical Specialty Costs 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of Drug Spend 30% 1% 70% Percentage of Membership Affecting Drug Spend 99% Specialty Traditional 35% 13% 9% 43% Why Integrate the Specialty Medical and Pharmacy Strategies? Other Hospital Outpatient Physician Office Home Health Hemophilia patient s annual cost: $850K; effective patient care saves 62% of overall care cost 5 Biosimilar appropriateness; 26% savings on $11B drug category 4 Ensuring adherence monitoring, $200B annual US cost from drug misuse 2 Lab verification; 1 Rx to 1 of the only 96% of Cystic Fibrosis patients not qualified for drug costs $300,000/yr 3 6

7 Specialty Drug Financial Impact Modeling Tool v1.0 What It Is: Analyzes a client s potential financial exposure to key specialty/high cost drug categories Targets key drugs in the pipeline, recently released drugs, specialty drugs, high cost diseases, and expanded indications for existing therapies The tool was developed with FDA guidelines and is piloted with the following disease states: Hepatitis C High cholesterol PCSK9 Multiple Sclerosis Cystic Fibrosis Idiopathic Pulmonary Fibrosis Uses medical and Rx data from InfoLock along with population disease rates Model will continue to be refined with new drugs, disease states, & clinical data Model shows minimum costs not inclusive of physician drug administration fees What It Is Not: Predictive tool for a client s TOTAL specialty spend 7

8 Potential Additional 2016 Rx Costs UNIVERSITY OF ALASKA Impact on 2016 Budget Paid Claims Idiopathic Pulmonary Fibrosis (narrow definition): Individuals with one or more paid claims in the reporting period with ICD 9 code PCSK9 Inhibitors: Unique Members with Elevated LDL-C despite being on statins or can't tolerate. Hepatitis C: Individuals with one or more paid claims in the reporting period with ICD 9 codes , , , , or Multiple Sclerosis: Individuals with one or more paid claims in the reporting period with ICD 9 code 340. Cystic Fibrosis: Individuals with paid claims for one inpatient visit or two outpatient visits with a diagnosis of Cystic Fibrosis. Number below is 28% of CF patients, minus those taking Kalydeco Total Potential Members Treatment $96,000 $12,000 $85,000 $40,000 $300,000 Percent in % 15% 20% 15% 100% Budget Impact $48,000 $363,600 $408,000 $168,000 $300,000 $1,239,600 PMPY $6 $43 $48 $20 $35 $145 New Drug Introductions Esbriet or Ofev, both approved 10/2014 Praluent (alirocumab) - 7/24/2015, Reptha (evolocumab) - 8/27/2015 Includes Sovaldi, Harvoni, Viekira Pak & drugs that must be taken with them Zinbryta (daclizumab) 6/2015 Orkambi - 7/5/2015 8

9 Savings Insight Based upon the limited data available in the claims experience, it creates a challenge to provide a full assessment of the savings affiliated with the current arrangement To project the estimated savings we ve leveraged the average per script savings achieved over Lockton s book of business in 2014 Potential Annualized savings: $200k - $350k Total annualized savings opportunity: $200,000 to $350,000 Renogiate AWP discounts, Rebates, Dispensing Fees Implement best-in-class contract language Quarterly Audit provision with full reconciliation annually Lockton Companies, Proprietary and Confidential 9

10 Lockton Pharmacy Analytics Lockton s Pharmacy Analytics practice supports plan sponsors in assessing the current and future cost drivers of their pharmacy benefit plan and deploying strategies to enhance value and mitigate spending. Specialty Drug Spend Mitigation Member Cost Share Strategies Detailed Claims Analysis PBM Marketing Our experienced consultants will provide plan sponsors guidance on how to address immediate needs and opportunities while also positioning the plan to successfully manage future challenges. Clinical Savings Analysis Formulary Management Contract Optimization Prospective Cost Modeling 10