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AIS's Health Business Daily
Featured Story October 20, 2008 Health Insurers Roll Out Value-Based Prescription Drug Plans, Tap a Growing Demand Reprinted from DRUG BENEFIT NEWS, biweekly news, data and business strategies for health plans, PBMs and pharmaceutical companies. By Neal Learner, Managing Editor, (nlearner@aispub.com) More and more health plans, including WellPoint, Inc. and a subsidiary of UnitedHealthcare, are rolling out value-based insurance design (VBID) programs in response to growing demand for the concept that aims to boost pharmaceutical adherence by lowering barriers to access. Interest in value-based benefits, pharmacy executives say, will continue to expand alongside emerging evidence that the programs improve overall member health and avoid more costly medical expenses later on. Some health plans and PBMs, meanwhile, are moving their VBID programs beyond simply lowering copayments on "high value" drugs, and are addressing educational hurdles to compliance, as well as targeting programs on highest-risk members. Value-based designs have been "quickly embraced by the consultant community," says Brian Sweet, chief pharmacy officer at WellPoint. Consultants are "aggressively engaging employers" in the concept, he told a Sept. 18 AIS audioconference on how value-based programs can provide a return on investment (ROI). Many of the consultants point to the experience of Pitney Bowes Inc., a mail-distribution company that helped pioneer the VBID concept in 2002. Jack Mahoney, M.D., medical director at Pitney Bowes, told the AIS audioconference that the firm's VBID programs generated a roughly 2.6 to 2.8 times return on investment. For example, under Pitney Bowes' VBID program for asthma patients, the possession rate for long-acting asthma controller drugs went from 49% in 2001 to 66% in 2007, Mahoney said. The increased possession rate of these drugs correlates with an observed 22% decline in emergency room use and a 62% decline in hospital admissions during the same time period, he said. Like many VBID programs, WellPoint's offerings focus on disease states in which improved Rx adherence can make a significant clinical and financial difference, Sweet said. Take cholesterol-lowering statins, for example. WellPoint has demonstrated in several different plans a roughly $100 per-member per-month reduction in total costs of care when members are compliant with statins, he said. WellPoint to Offer VBID Options WellPoint's programs integrate pharmacy and medical components, and are designed to address both "financial as well as educational barriers to Rx and preventive medical adherence," Sweet added. WellPoint value-based benefit design (VBBD) offerings, as the company calls them, for 2009 include: Product model No. 1, VBBD by service: Waive or reduce copays or coinsurance for all members taking selected drugs, such as statins, or utilizing selected preventive services, such as blood pressure tests. The product does not require a diagnosis or confirmation of a specific condition for the member to access the VBBD benefits. Product Model No. 2, VBBD by condition: Waive or reduce copays or coinsurance for members identified with specific conditions. The product design requires a diagnosis for the specific condition for the member to access VBBD benefits. Product Model No. 3, VBBD by condition severity: Waive or reduce copays or coinsurance for "targeted" high-risk members who are "eligible" participants in WellPoint's Health Management Corp. (HMC) disease management (DM) programs. The program targets members with the highest risk stratification, and access to the value-based benefit is dependent upon being eligible for engagement in the DM program. Product Model No. 4, VBBD by DM engagement: Waive or reduce copays or coinsurance for "targeted" high-risk members who are "active" participants in HMC's DM programs. The program targets members with the highest risk stratification and provides an incentive to take action to better manage their health. Access to the value-based benefit is dependent upon active engagement in the DM program Meanwhile, other health plans are unveiling their own value-based programs. On Sept. 24, Health Plan of Nevada (HPN) said it was reducing copays on several widely used brand drugs for chronic illnesses — such as diabetes, asthma, high blood pressure and seizures — under its Medicare Advantage HMO plan, Senior Dimensions. The program became effective Oct. 1. The drugs, which had copays of $20 to $30, will now have $3 to $5 copays in Senior Dimensions, said HPN, a subsidiary of UnitedHealthcare. A three-month supply of the drugs via mail-order delivery, which previously had copays of $50 to $75, will have $5 to $9 copays, depending on the plan, the company added. Steven Evans, M.D., vice president of medical affairs and pharmacy director at HPN, said the idea for the program came from Pitney Bowes. VBID is a "huge area of debate in the pharmacy arena," Evans tells DBN. "We're hoping that people will be more compliant and end up with better overall health." VBID Program Uses Predictive Modeling Prime Therapeutics, LLC, a PBM owned by Blue Cross and Blue Shield plans, is another large player that recently introduced a VBID program. The program uses predictive modeling of medical claims data to identify high-risk members, such as those who have had a heart attack or are dealing with multiple conditions, says Patrick Gleason, Pharm.D., director of outcomes assessment at Prime Therapeutics. In addition to having reduced copays, eligible members also are exempt from any step-therapy edits or prior-authorization restrictions at the point of purchase, he says, explaining that the idea is to reduce any and all barriers to high-risk patients. Identifying high-risk members through predictive modeling sets Prime Therapeutics' VBID model apart from other value-based offerings, Gleason asserts. Most VBID programs simply lower everybody's cost share for drugs in certain categories, he explains. "Because they don't have a method to stratify the population, we believe that is cost ineffective," Gleason adds. As more VBID programs come to market, health plans and PBMs acknowledge that they face some hurdles from employers who fear they will be deluged with complaints from workers who are angry that colleagues are receiving cheaper drugs. But those complaints
haven't yet materialized, according to Mahoney. "Interest in disparate
treatments is one that our attorneys were all over," Mahoney said.
"There was great concern about it. Frankly, in six years, we have
yet to have an employee complaint of disparate treatment. As I talk
to other employers, they have not had it either. There is just some
recognition among people that some will need treatment or financial
support." |
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