PCMA drug copay presentation 02 2012 long

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This is a long version of what I'm presenting at PCMA on 2/8/12. It includes more data that I'll be sharing and summarizing during my verbal presentation.

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  • http://www.pcmanet.org/images/stories/uploads/2011/Nov2011/visante%20copay%20coupon%20study.pdfFirst, let’s look at the basics. Given the audience here, I’m sure you’ve all read the Visante study that they did for PCMA in November of 2011.
  • The availability of these programs is growing. You can go online and find these programs at many sites, and you can see the growth here. The unknown question is how much they are being used. Today, everyone I talked to is struggling with how to tag which claims process with a copay card used.
  • But, the lack of data is something that makes this an opaque topic. If the data ever becomes transparent, this issue will either quickly die or will get magnified based on what that shows. Until then, the official PBM position is that copay cards are bad. I talked to almost all of the top 10 PBMs over the past few weeks to validate this.
  • And, last summer, I had 16 different PBMs participate in a survey on the topic. As you can see here, they were generally concerned, but they weren’t sure of the impact.
  • On the other hand, even though there are more and more copay cards out there, the actual utilization of 3rd tier drugs has actually dropped over the years although the range is pretty narrow.
  • That being said, I think Everett’s quote from Express Scripts does a pretty good job of summarizing this if you really get behind the immediate reaction.
  • So, the reality is more complex. It takes into account the drug type (traditional versus specialty). It begins to look at the purpose of the copay card. Of course, no one has issues with PAP programs. The issues really are around commercial business where copay cards may influence patient decisions about drug selection and minimize the traditional PBM tools of formulary and copay.
  • Here’s generally how I look at the situation moving from the type of drug on the X axis and looking at the timing in the Y axis.
  • http://www.healthbusinessblog.com/2011/08/drug-co-pay-cards-can-we-all-just-get-along/Or here’s another similar quote that came out after my AIS webinar last year where I suggested that maybe there was a win-win around copay cards.
  • I personally struggle with some of the fundamental assumptions about why copay cards are used. The data is not clear in supporting what I believe are the primary assumptions for funding these programs.
  • Let’s look at one of the biggest myths out there first. Cost. While the latest data shows that 50% of the US population now is on the government payroll through food stamps, Medicare, Medicaid, Social Security, or other assistance, the Kaiser data here only shows 20% of people not filling a prescription as part of their card avoidance.
  • This is consistent with our data at Silverlink that shows only 14% of people not taking some healthcare action based on cost. Our 243,000 barrier surveys were done over the past 2 years looking at preventative activities and refill data.
  • So…if cost isn’t the issue, then one might assume that copay cards are great influencers of physicians that understand the cost of the medications that they prescribe and want to help their patients. But, again, if you look at the published data by Will Shrank, it shows that physicians don’t worry about formulary or OOP costs. They see that as the pharmacist’s job.
  • The next key assumption is that these copay cards work. I talked to several people that manage these programs and the data wasn’t clear. In the best case, it appeared that they increased the average days supply for a patient by 30-45 days (or about 10% improvement in PDC or MPR). And, according to the Visante study with PCMA, these programs get a 4:1 – 6:1 ROI leading to about $4B in spend a year.
  • http://www.drugchannels.net/2012/01/is-pfizers-lipitor-strategy-working.htmlThe last key question or myth here is that copay cards will slow the shift to the generic after the patent expires on a brand drug. We have a great case study unfolding before our eyes. One the one hand, I have to hand it to Pfizer for creatively trying a number of programs to sustain the brand utilization. And, most of the data seems good. But, Adam Fein shared a chart a few weeks ago that created some skepticism here. He shows that the shift to generics for Lipitor is actually happening faster than in prior cases…even with all the efforts by Pfizer. (I was surprised.)
  • Of course, if I’m sitting in your seats and I’m responsible for a drug, I’m focused on the issue of copayments going up. As this study from JAMA showed and we’ve all talked about relative to VBID, copay increases do affect adherence…
  • http://www.benefitdesignreport.com/CostSharing/RetailCopays/tabid/84/Default.aspxAnd, copays continue to go up. Although as a percentage of drug costs, they’ve stayed flat for years.
  • http://www.usatoday.com/news/health/2008-03-04-placebo-effect_N.htm
  • But, the question now is how will PBMs and payers respond to increased use of copay cards. On the one hand, you have CVS Caremark who removed over 30 drugs from their 2012 formulary with about ½ of them having some type of copay card in the market. Generally, when I talked to PBMs, this was their primary reaction. It’s the cleanest and most effective strategy, but it’s also the most disruptive. This slide shows the spectrum of opportunities. Of course, as David Snow talked about last year, they’d all like to figure out how to do this at the POS, but that hasn’t happened and seems to be more difficult as copay cards look more like pre-paid debit cards.
  • And, when I survey people last year, you can see that this was where people felt strongest.
  • Increasing mail order utilization was another easy answer to avoid use of copay cards since most PBMs won’t accept them. This is an interesting one since PBMs generally don’t want brands at mail order since they don’t make money there (generally). And, given the mail order drops over the past few years, this is a challenge for them in general and copay cards have created some buzz about pharma wanting to actually encourage 90-day retail utilization for this exact reason.
  • At the end of the day, it’s still a confusing topic. The constituents are torn. The data is inconclusive. There are issues that exist.
  • But, I personally believe that copay cards that were used tactically to address adherence, improve outcomes, and reduce overall healthcare costs could be a win-win. That’s a hard sell on MSBs like Lipitor, but a lot easier on specialty drugs. On the flipside, as a I mentioned earlier, I think pharma could collaborate with payers to drive adherence in less controversial ways.
  • So, what I proposed last summer was the following which I still think makes sense:
  • In summary, …
  • PCMA drug copay presentation 02 2012 long

    1. 1. How Copay Coupons Are Influencing the Market PCMA CONFERENCE George Van Antwerp SVP, Pharmacy Solutions Silverlink Communications, Inc. February 8, 20121 | FEBRUARY 2012 ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    2. 2. $32B estimated increase in payer costs over the next decade ~340 programs ~100-125M Rxs using co-pay cards 3% of the market 13% of branded Rxs MA is the only state to prohibit Government payers are excludedSource: Visante study from www.pcmanet.org 2ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    3. 3. Significant Copay Card Growth Over 2 Years 400 350 340 310 300 275 250 200 150 100 86 50 0 July 09 April 11 July 11 Sept 11Source: Visante study from www.pcmanet.org 3ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    4. 4. Wizard of Oz pulling back curtain THE PERCEPTION. There is an “untrackable” mechanism which pharma has created to get around formularies and directly influence patient and physician drug selection4 | FEBRUARY 2012
    5. 5. 47% of those surveyed definitely thought co-pay cards or coupons impacted their ability to manage trend. No one disagreed. N=16Source: Silverlink web survey in mid-2011 5ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    6. 6. Tier 3 Utilization Has Remained Flat for Years 80 70 60 50 Tier 1 40 Tier 2 30 Tier 3 20 10 0 00 01 02 03 04 05 06 07 08 09 10 11Source: Drug Benefit News Volume 11, Number 16, p.5. 6ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    7. 7. “We have two different perspectives on coupons, depending on how they are used. One, they can be used to subvert the formulary and cause the patient to not adhere to the formulary. That’s bad for the whole industry. However, if it’s being used to alleviate the financial difficulties of acquiring a drug, it’s not necessarily a Trade Relations Officer for Express Scripts, Inc. Everett Neville, Chief problem.”Source: Drug Benefit News, Feb. 4, 2011 7ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    8. 8. Wizard of Oz pulling back curtain THE PERCEPTION. There is an “untrackable” mechanism which pharma has created to get around formularies and directly influence patient and physician drug selection THE REALITY. Co-pay cards are a multi-dimensional issue with limited facts and some opportunities for win-win.8 | FEBRUARY 2012
    9. 9. Different Ways That Co-pay Cards Could Get Used Adherence WIN-WIN Refill PROBLEMATIC New Start MSB SSB SpecialtyMSB = multisource brand; SSB = single source brand 9ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    10. 10. “It seems the best strategy for a pharmaceutical company is to price their drug as high as they possibly can and offer that co-pay assistance broadly” Joshua Schimmer, biotechnology analyst at Leerink Swann, an investment bankSource: NY Times - http://www.nytimes.com/2011/01/02/business/02coupon.html 10ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    11. 11. “The only reason pharmaceutical companies issue these cards is to circumvent financial incentives put in place by health plans to encourage the use of less expensive alternatives, whether branded or generic. The cards are a good value for drug companies because they remove the price signal from the patient, driving up third-party reimbursement. The result is higher pharmacy costs, which drive up total medical costs and health plan premiums.” David Williams, Health Business Blog, co-founder of MedPharma Partners LLCSource: Health Business Blog http://www.healthbusinessblog.com/2011/08/drug-co-pay-cards-can-we-all-just-get-along/ 11ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    12. 12. Potential Myths About Copay Cards We need to offer cards because cost is a large issue around non-adherence Costs will influence physician choice Copay cards are a cost effective way to improve adherence Copay cards can delay conversion to generics for MSBs 12ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    13. 13. Cost Isn’t the Only Barrier 13ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    14. 14. Overall Barriers to Care Barriers to Care Across All Programs 30% 27% 27% 25% 20% 20% 15% 14% 12% 10% 5% 2% 0% Doesnt Feel Need Time / Too Busy Doctor Didnt Recommend Cost Nervous / Anxious Transportation N = 243,234Source: Silverlink analysis of barrier surveys conducted across clients 14ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    15. 15. Physicians Do Not Feel Accountable for ManagingPatient’s Formularies and Out-Of-Pocket Costs 50% 45% 40% 35% 30% % of Physicians Physicians 25% Pharmacists 20% 15% 10% 5% 0% Strongly Somewhat Neither Somewhat Strongly Disagree Disagree Agree AgreeSource: Shrank et al. AJMC, 2005 15ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    16. 16. Physicians Like Co-pay Cards Too Are you more likely to prescribe a drug if you are aware that a co-pay card is available? “Using the cards allows my patients to be able to afford more effective 15% medications by reducing cost.” 37% Much more likely “Co-pay cards are usually attached More likely with some patient-directed 800 number or a website… it frees up 48% Not more likely my time and helps them financially.” “I see it as fighting fire with fire. As long as insurance companies continue to raise co-pays for superior, branded drugs, this is a fair response.” N=102 physiciansSource: CLSA report 16ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    17. 17. 30-45 days was the average increase in days supplied quoted by several sources in evaluating the ROI of these programs $4B in spend 4:1 – 6:1 ROISource: Visante study from www.pcmanet.org 17ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    18. 18. Source: Chart from Drug Channels http://www.drugchannels.net/2012/01/is-pfizers-lipitor-strategy-working.html 18ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    19. 19. Systematic Review of The Effect of Copaymentson Adherence $ Increased cost-sharing For every 10% increase in For patients with CHF, lipid associated with lower rates cost sharing, drug use disorders, diabetes, and of drug use, worse decreases by 2-6% schizophrenia, higher adherence among existing copayments are associated users, and more frequent with increased use of discontinuation of therapy medical servicesSource: Goldman DP, et al JAMA. 2007 19ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    20. 20. Rising CopaysSource: PBMI Prescription Drug Benefit Cost and Plan Design Report: 2011-2012 Edition 20ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    21. 21. And Cost (Unfortunately) Can Influence Outcomes “Of the patients who took the full-price pill, 85% said they felt less pain afterward, compared with 61% of those who took the 10-cent pill. Because both groups received the same sugar pills, the power of the placebo effect in pain relief was illustrated.” USA Today, “Placebo study tests „costlier is better‟ notion” (MIT Study)Source: USA Today http://www.usatoday.com/news/health/2008-03-04-placebo-effect_N.htm 21ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    22. 22. There are a Spectrum of Options for Trying to ManageCo-pay Cards Adopt a restricted or closed formulary Increase co-pay tier differentials Implement member-pays-the- difference without DAW exception Implement preferred drug step therapy rules Leverage mail order channel where co-pay cards aren’t generally accepted Add contract language to prohibit the use of drug manufacturer coupons Increase member education effortsDAW = dispense as written 22ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    23. 23. Most People Would Move the Drug To Not Covered When do you believe co-pay cards or coupons impact your ability to manage trend, how would you suggest limiting their use? 64% Would move drugs to “not covered” Work directly with pharmacies to 29% limit their use Implement utilization management 21% programs 21% Legislate against them N=16Source: Silverlink web survey in mid-2011 23ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    24. 24. The Easy Solution Of Mail Order Is Under PressureSource: Chart from Barclays Capital based on IMS Health data 24ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    25. 25. Overall, 26% Of Consumers Say They Have UsedA Coupon Or Copay CardSource: Pharmacy Satisfaction Pulse Survey Data March 2011ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    26. 26. Generalized Opinions By Constituent Opinion PBM / Payer Co-pay cards are bad. They interfere with our ability to manage trend and our formulary process. Pharmacy Co-pay cards are a part of life. If a patient has one, we’ll take it and use it. Manufacturer Co-pay cards are less expensive than samples. They’re easier to track and distribute. They provide us with a way to connect with the patient. They relieve the patient’s financial barriers. Physician If co-pay cards help my patients to take the drug I prescribe, I support them. Patient My doctor wrote for the medication. Costs keep going up and this is saving me money. 26ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    27. 27. 27ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    28. 28. A Potential Co-pay Card “Pledge”(From A Payer Orientation)Never use on Manage Establish a Only offer Use should be MSBs distribution system to where medical focused within through track utilization savings are specialty pharmacies at the POS created due to and physicians increased MPRPOS = point of sale 28ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    29. 29. Summary1 Information is limited2 I’m skeptical about some of the baseline assumptions3 Control will be difficult4 Even if they work, there are lower cost options to drive adherence5 They will continue to grow6 Stay tuned for an FDA study due out in 20127 Everyone will be watching the Lipitor case study 29ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    30. 30. Q&AENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.
    31. 31. ENGAGE. EDUCATE. EMPOWER. © 2012 Silverlink Communications, Inc. All rights reserved.

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