The Impact of Medicare Part D on the Percent Gross Margin Earned by Texas Independent Pharmacies for Dual Eligible Beneficiary Claims

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1 The Impact of Medicare Part D on the Percent Gross Margin Earned by Texas Independent Pharmacies for Dual Eligible Beneficiary Claims Angela Winegar, M.S., Marvin Shepherd, Ph.D., Ken Lawson, Ph.D., and Kristin Richards, Ph.D. ISPOR 13 th Annual Meeting May 5, Center for Pharmacoeconomic Studies College of Pharmacy The University of Texas at Austin

2 Presentation Roadmap Setting the Stage Methodology Results Conclusions 2

3 Setting the Stage What we know Medicare Part D sponsors reimburse pharmacies for 40% of all prescriptions Dual eligible patients switched from Medicaid to Part D coverage Independent pharmacies most vulnerable Anecdotal reports of slow and low payments What we have left to uncover The financial impact of Medicare Part D on independent pharmacies 3

4 Statement of Purpose Describe dual eligible claims before and after Medicare Part D Compare the percent gross margin earned by Texas independent pharmacies for Medicaid and Medicare Part D claims Compare Part D claims controlling for Prescription Drug Plan (PDP) Sponsor 4

5 Methodology - Study Population Study timeframe Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Medicaid 152,521 claims Transition 0 claims Medicare Part D 305,090 claims Inclusion criteria Texas independent pharmacies (n = 313) Dual eligible patients over the age of 21 (n = 24,576) 5

6 Methodology - Financial Measures Pharmacy Financial Measures Total Revenue = Patient Payment + 3 rd Party Payment Dollar Gross Margin = Total Revenue Ingredient Cost Percent Gross Margin = Dollar Gross Margin / Total Revenue Gross Margin adjusted to 2005 dollars for multi-year comparisons 6

7 Results: Medicaid vs. Medicare 7 Medicaid patients were: Slightly older (70.2 vs. 69.4) Slightly more likely to be female (67.5% vs. 66.5%; p < 0.001) Taking more prescriptions per month (2.9 vs. 2.3; p < 0.001) Medicaid prescriptions were: Not significantly different in terms of generic drug usage Supplied in larger quantities (35.1 days vs days; p <0.001)

8 Results: Medicaid vs. Medicare Describe and compare payment data Mean Payments per Claim Payment Value ($) $90.00 $80.00 $70.00 $60.00 $50.00 $40.00 $30.00 $20.00 $10.00 $0.00 $84.07 $84.29 $66.17 $71.21 $5.05 $0.21 Patient Payment 3rd Party Payment Total Payment Medicaid Part D All payments were significantly different (p < 0.001) 8

9 Results: Medicaid vs. Medicare Describe and compare gross margins Percent Gross Margin (Unadjusted) Percent Gross Margin (Adjusted) Percent Gross Margin (Adjusted) Controlling for Proportion of Generic Drugs 30.0% 25.0% 20.0% 15.0% 10.0% 26.7% 17.0% 30.0% 25.0% 20.0% 15.0% 10.0% 26.7% 20.4% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 8.7% Brand 8.3% 39.9% Generic 29.5% Medicaid Part D Medicaid Part D Medicaid Part D All differences were significant (p < 0.001) 9

10 Results: Comparison of Top 5 PDP Sponsors Describe and compare payment data $14.00 Patient Payment $90.00 Part D Sponsor Payment Payment Value ($) $12.00 $12.99 $10.00 $8.00 $6.00 $4.00 $2.00 $3.20 $1.96 $2.13 $2.44 $0.00 Sponsor A Sponsor B Sponsor C Sponsor D Sponsor E Payment Value ($) $80.00 $82.89 $79.32 $70.00 $60.00 $66.33 $62.92 $50.00 $40.00 $45.01 Sponsor A Sponsor B Sponsor C Sponsor D Sponsor E Total Payment Received by Pharmacies for Part D Claims $90.00 Payment Value ($) $80.00 $70.00 $60.00 $50.00 $68.29 $65.05 $58.00 $86.09 $81.76 $40.00 Sponsor A Sponsor B Sponsor C Sponsor D Sponsor E 10

11 Results: Comparison of Top 5 PDP Sponsors Describe and compare gross margins 25.0% Percent Gross Margin 40.0% Percent Gross Margin Controlling for Proportion of Generic Drugs 20.0% 15.0% 14.5% 19.5% 15.3% 19.8% 30.0% 20.0% 29.7% 30.8% 25.0% 21.6% 19.2% 10.0% 5.0% 12.0% 10.0% 3.5% 5.9% 2.8% 3.0% 5.3% 0.0% Sponsor A Sponsor B Sponsor C Sponsor D Sponsor E 0.0% Brand Generic Sponsor A Sponsor B Sponsor C Sponsor D Sponsor E 11

12 Implications Over 1,100 independent pharmacies closed in 2006 Independent pharmacy benefits from this study: Increased knowledge of the financial impact of Part D More awareness of differences among various PDP sponsors More incentive to evaluate each Part D plan 12 Government gains awareness of financial impact of Part D

13 Limitations Limited generalizability Analysis done at PDP sponsor level Ingredient cost may not represent acquisition cost National consumer price index may not be appropriate 13

14 Summary 23.6% reduction in percent gross margin from Medicaid to Medicare Part D Significant variability in the percent gross margin paid by different PDP sponsors Proportion of generic prescriptions is an important predictor of percent gross margin Funding received from: The Community Pharmacy Foundation 14

15 Questions? 15