Prescription Drug Utilization
& Opioid Abuse
July 16, 2013
Mona Chitre, PharmD, CGP
Vice President, Pharmacy Management
Excellus BlueCross BlueShield
Pharmacy Management: Market
Landscape
• Impact of Prescription Benefits
• Specialty Medications
• Price Increases
• Trend Management Opportunities
• Opioids
Why are Prescriptions important:
•#1 Benefit: Most commonly used benefit
• 67-70% use the drug benefit each year
• 12-15 prescription fills per person per year
•#1 Cost: Drugs are the top cost driver
Service Bucket
PMPM Allowed: Rx extracted from
buckets and consolidated
Drug (Rx and Medical Benefits)
$ 94.03
Physician
$ 93.44
Outpatient
$ 70.93
Inpatient
$ 60.96
How does Rx affect benefit plans?
Medical Benefit
•
•
•
•
•
•
•
Hospital
Physician Office
Outpatient Facility
Clinics
Infusion centers
Home Infusion
DME
• Drug Costs: 5-8% of total
medical cost ($20-$25 pmpm)
Pharmacy Benefit
• Retail Pharmacy
• Mail Pharmacy
• Specialty Pharmacy
• Drug Cost : 20-25% of total
health care cost ($75-$85
pmpm)
Prescription Benefit
Medical Benefit
Cancer
Diabetes
Antidepressants
Hypertension
Rheumatology
Psoriasis
Contraceptives
Hemophilia
Vaccines
Multiple Sclerosis
Immunoglobulins
Hyperlipidemia
Osteoarthritis
PPIs
Asthma
Enzyme
Replacement
Glaucoma
Pulmonary Arterial
Hypertension
Today’s pharmaceutical benefit reality
$20 – generic Rx
$200 – brand Rx
$2,200 – specialty Rx
SPECIALTY PHARMACEUTICALS
7
New Technology: Specialty Drugs
General Description:
• High Cost
• Biologics
• Pharmacy or Medical Benefit
(Oral, Injectable, Infusion)
• Monitoring Required
• Targeted
• Chronic or genetic
conditions with still an
unmet need
Drug
Condition
Annual Cost
Vectibix
Cancer
$100,000
Enbrel
Rheumatoid
Arthritis
$16,000
Cinryze
Hereditary
$450,000
Angioedema
Juxtapid
Familial
High
Cholesterol
$1,000,000
Top Ten Drug Projections
Specialty Drug: Employer Impact
Employer: 200 employees (450 total with coverage)
• 5300 Prescriptions/ year
• Average employer cost/Rx: $60
• Total Annual Rx cost for employer: $320,000
Specialty Drug Impact: Tykerb
• Oral drug used in combination for breast cancer.
• Incremental Added Cost: $55,000/ year
15% increase in Rx expense that year
10
Specialty Drug: Employer Impact
Large multiple employer coalition:
•
•
•
•
41,000 covered lives
Medical Drug PMPM: $14.47 (07-08)
Medical Drug Trend: 50% over 2 years
Specialty Drug Impact:
– 2 of the covered members treated with Fabrazyme
– Annual cost of > $518,000
This drug accounted for 8% of the medical expense
11
“Cancer Trends Demand Call To Action”
The Tipping Point
“At Memorial Sloan-Kettering
Cancer Center, we recently
made a decision that should
have been a no-brainer: we
are not going to give a
phenomenally expensive new
cancer drug to our patients”
• Zaltrap v. Avastin
– Same Efficacy
– $11,000 difference
Cost Trends
2012/2013 Sample Specialty Rx Approvals
Drug
Manufacturer Route
Approval
Launch
(est)
Annual Cost
Oral
Advanced renal cell
carcinoma
1/27/2012
2/1/2012
$75,000/yr
Genentech
Oral
Basal cell carcinoma
1/30/2012
2/7/2012
$75,000/yr
Vertex
Oral
Cystic Fibrosis
1/31/2012
2/7/2012
$294,000/yr
Corcept
Oral
Cushings Disease
2/17/2012
5/1/2012
$180,000/yr
Pfizer/Protalix
IV
Gaucher Disease
5/2/2012
5/3/2012
$180,000/yr
Genentech
IV
HER2-positive Breast CA
6/11/2012 6/25/2012
$71,000/yr
Oral
Familial High Cholersterol
12/21/201
2
Inlyta (axitnib) Pfizer
Erivedge
(vismodegib)
Kalydeco
(ivacaftor)
Korylm
(mifepristone)
Elelyso
(taliglucerase
alfa)
Perjeta
(pertuzumab)
Juxtapid
(pertuzumab)
Kadylca
(traztuzumab
emtansine)
Indication
Aegerion
Genentech
IV
HER2-positive Breast CA
2/22/2013
2/1/2013
$1,000,000
$94,000
Pricing and Price Increases
Case Study: Multiple Sclerosis
New Technology:
2010: 2 New agents - 1st Combination drug and 1st Oral Agent
Significant Price Increases:
• 2006 Price - $ 15,000
• 2010 Price - $37,000
METRIC
EHP 2 year Trend
COST
40%
USE
16%
Mean Ingredient Cost Copaxone Compared with CPI
$3,000
$2,800
$2,600
$2,400
$2,200
COPAXONE
$2,000
Consumer Price Index
$1,800
$1,600
$1,400
$1,200
2004Q1
2004Q2
2004Q3
2004Q4
2005Q1
2005Q2
2005Q3
2005Q4
2006Q1
2006Q2
2006Q3
2006Q4
2007Q1
2007Q2
2007Q3
2007Q4
2008Q1
2008Q2
2008Q3
2008Q4
2009Q1
2009Q2
2009Q3
2009Q4
2010Q1
2010Q2
$1,000
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Drug Cost Trends: Upstate New York
$250.00
$208.38
Average brand name drug cost *
$185.89
$200.00
$167.74
$155.04
$135.58
$150.00
$120.05
$190 Difference
$100.00
$100 Difference
Average generic drug cost *
$50.00
$19.63
$18.30
$19.12
$18.68
$19.28
$18.16
2006
2007
2008
2009
2010
2011
$0.00
Trend Management: GENERICS
“Ask your doctor if a generic is right for you”
Employer Impact: Case Study
• Employer: 200 employees (450 total with coverage)
•
•
•
•
Avg 12 Rx/person/yr: approx. 5,300 Rx
Avg employer cost/Rx: $60
Generic Fill Rate: 65% (3,445 of the Rx are for generic)
Total Annual Rx cost for employer: $318,000
• Generic Opportunity: Increase GFR to 70%
•
•
•
•
265 brand drug Rx changed to a generic option.
Cost saving per Rx: $100
Savings to employer: $26,500 (8% of spend)
Savings to employee: 200-$400+/year
Each 1 point increase in GFR can reduce Rx spend by 2-3%
Trend Management: Use Management
Managed Rx
Unmanaged Rx
Generic Fill Rate
85.6%
74.2%
Brand PMPM
$54.38
$102.09
0.4%
26.7%
Generic PMPM
$24.42
$30.11
Generic PMPM
Trend
-9.2%
2.5%
Total PMPM
$78.80
$132.20
Total PMPM Trend
-2.6%
20.5%
Est Annual Spend
$2,124,289
$3,237,091
Brand PMPM Trend
$160.00
Total $ PMPM
Measure
$120.00
20.5
$80.00
$40.00
$0.00
201301
201302
201303
Managed
Unmanaged
Managed Trend
Unmanaged Trend
201304
Data based on claims incurred January – April 2013
• Rx management programs: Generic Trial Program, Prior Authorization
and Step Therapy encourage equally effective lower cost options to
help manage trend and lower member out of pocket cost.
• Groups with unmanaged Rx are incurring significantly higher Per
Member Per Month (PMPM) costs than groups with managed Rx
benefits
Opioid Impact
Balancing the need for opioids
“Overdoses involving prescription painkillers are at epidemic levels
and now kill more Americans than heroin and cocaine combined.
States, health insurers, health care providers and individuals have
critical roles to play in the national effort to stop this epidemic of
overdoses while we protect patients who need prescriptions to
control pain.”
CDC Director Thomas Friedan M.D., M.P.H.
Although evidence is limited, chronic opioid therapy (COT) can be
an effective therapy for carefully selected and monitored patients
with chronic non-cancer pain (CNCP).
The American Pain Society and the American Academy of Pain Medicine
expert panel
21
Statistics
• Overdose deaths involving opioid pain
relievers (OPR) have increased and now
exceed deaths involving heroin and cocaine
combined. OPR involved in 14,800 deaths in
2008
• More ED visits related to misuse or abuse of
pharmaceuticals compared to use of illicit
drugs
Prescription Drug
Overdose Deaths,
2008
26%
OPR Overdose
Deaths
74%
Other Rx
Drugs
• By 2010, enough OPR were sold to medicate
every American adult with a typical dose of 5
mg of hydrocodone every 4 hours for 1 month
• 17 percent of teens say they have used a
prescription medicine at least once in their
lifetime to get high or change their mood.
* Significantly lower than 2009 levels
22
Impact to Stakeholders in Healthcare
• 40 people die every day from
overdoses involving opioids
such as hydrocodone,
oxycodone and oxymorphone
• The average annual cost per
capita for opioid abusers has
been calculated at $16,000
compared to $1,800 for nonabusers
Wasted
healthcare dollars
• Nonmedical use of OPR
costs insurance companies
up to $72.5 billion annually in
health-care costs
23
Excellus BlueCross Blue Shield Team
Clinical
Pharmacy
Management
Medical Director
Behavioral Health
Non-Clinical
Special
Investigations Unit
Data Analytics
Communications
24
Opioid
Mailing
Suboxone®
Initiative
Identification
and
Stratification
Align
Formulary
Integrated
Approach
25
Prescribing Summary - Cover Letter
26
Example Report
27
Results of Opioid Mailing
Pharmacy
Billing Errors
Fraudulent
RXs by MD
staff
Stolen
Prescription
Pads
Negative
Urine Drug
Screen
Suboxone®
Provider
testament
28
Provider survey
What frequency of mailing is
appropriate?
Was mailing helpful?
6.3%
More frequently
12%
32.4%
Yes
88%
Same
No
61.3%
Less frequently
Based on 330 respondents
Action Taken
25%
Did you take action?
20%
21.60%
18.50%
15%
41%
59%
Yes
10%
No
5%
9.10%
1.50%
0%
Contacted
other
prescriber
Contacted
Contacted
Contacted
insurance patient listed pharmacy
company
29
Step Three - Promoting Outpatient Detoxification
• Suboxone® - Under the Drug Addiction Treatment Act (DATA), limited to
physicians who meet certain qualifying requirements (authorized training,
addiction medicine specialty)
• Physician Engagement:
– Upstate New York has a shortage of physicians who can prescribe Suboxone®
for opioid dependence
• Advantages of therapy:
– Withdrawal symptoms can be managed safely and effectively in their home
environment that incorporates support from the family.
– Significant MEDICAL cost savings. Medical costs associated with inpatient
detox can cost upwards of $1,200/day. Outpatient detox costs the health plan
less than $300/day (excluding drug costs).
• Disadvantages of therapy:
– High cost
– Inappropriate use
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Results
Decrease in inpatient
detoxification by 10 percent
over a two year time period
(2009 – 2011)
Detox Medical Claims
Expense
$3,000,000
$2,194,857
$2,016,609
$2,000,000
Approximate 22% savings in
Medical costs for the same
time period
Significant increase in
members utilizing Suboxone®
therapy.
$1,718,065
$1,000,000
$2009
2010
2011, est
31
Last Thoughts
Insurers — the bad guys in so many policy debates
— can do a lot of good, keeping better track of the
number and types of controlled substances
policyholders are receiving.
The New Drug Crisis: Addiction by Prescription
Time Magazine
Monday, Sept. 13, 2010
32