Coverage and Payment for
Biotechnology and Medical
Devices
Academy Health
June 4, 2007
Thomas Weisman, MD, MBA
Ohio Medical Director
Anthem Blue Cross and Blue Shield
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Agenda
• P & T Process
• Cost of Care Committees
• Value Chain
• Transparency
• Examples
• Herceptin
• Specialty Pharmacy
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P & T Process
• Clinical Review Committee (CRC)
• Majority external representation
• Assessment of efficacy only
• Superior
• Equivalent
• Inferior
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P & T Process
• Value Added Committee (VAC)
• Internal representatives
• Cannot disadvantage superior
medication
• Within restrictions, business needs
rule
4
Cost of Care Committees
• Provider Relations
• Medical Directors
• Actuaries
• Support areas
• PBM
• Behavioral Health
• Operations
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Cost of Care Committees
• State level (OH)
• Central Zone (OH, IN, KY, MO, WI)
• Enterprise
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Value Chain
• Deconstruct and examine each
step/activity
• Is this an activity a customer would
pay extra for?
• Internal activities
• Device/Pharmaceutical
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Transparency
• Cost and (limited) quality information
• 38 elective services
• Cost
• Event or “shoebox” methodology
• Results presented in “bands”
• Can see impact on member responsibility
• Quality
• Volume of cases
• Access to Subimo information
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Transparency
•Consumer Directed Health Plans
(CDHP)
• Increasing consumer cost sharing
• Increasing consumer engagement
• Increasing market forces
• Increasing consumer focus on value
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chain
Herceptin
• Monoclonal antibody
• Useful in HER2 positive breast cancer
• Useless in HER2 negative breast cancer
• Cardiotoxic
• Expensive
• Weekly infusions, either alone or in
combination chemo regimens
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Herceptin
•
J9355 Summary by Financial Arrangement
(OH, IN, KY, MO, WI)
•
Total
23,618,980
•
After rem Medicare claims
18,668,905
•
After rem NASCO ASO
•
Tot allowed amt for Fully Ins
(after rem other ASO)
5,609,691
8,024,165
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Herceptin
United Health Care Pilot (anecdotal
information) demonstrated that 1112% of women receiving Herceptin
did not have documentation of
positive HER2 gene test
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Herceptin Proposal
•
Activate CG-DRUG-02 as of 7/30/2007—no
grandfathering
•
Require documentation of positive HER2
and attestation of normal cardiac function
•
Letter to all oncologists
•
Separate letter to oncologists with
members on Herceptin
•
Rapid update
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Herceptin Proposal
•
Create Provider Tool and Desktop
•
Training for MD’s and for RN’s in Pre-D, Med
Review and Precert
•
Provider Relations, Med Review, Pre-D and
Specialty Rx sign-on
•
Track PMPM (absolute and trend) compared
to states not managing Herceptin
•
Track denial rates
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Specialty Pharmacy
•
Pilot in California, Colorado and Nevada
•
84 (soon 87) medications require guidelinebased authorization for payment
•
Some medications (by volume, 5% of above)
will require purchase from PrecisionRx
Specialty Services including:
• Hemophilia factors
• TNF inhibitors ( but not Remicade)
• Synagis
• Somatotropins and Gonadotropins
• Hyaluronic acid derivatives
• Interferons
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• Enzyme replacement products
Conclusion
•
Health plan decision-making will be driven
by concerns for:
• Affordability
• Patient safety
• Value
•
Transparency and Consumer engagement
will reinforce above trends
•
Initial efforts focused on newer agents and
“low hanging fruit”
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Trademark Information
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and
Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance
Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health
Plans of Maine, Inc. In most of Missouri: RightCHOICE® Managed Care, Inc. (RIT), Healthy
Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates
administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO
Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans
and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In
New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance
Company. In most of Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue
Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies;
Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the
HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies.
Independent licensees of the Blue Cross Blue Shield Association. ® ANTHEM is a registered
trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue
Cross and Blue Shield Association
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