The Pharmacy Benefit

Host JC Scott speaks with two guests from Humana Pharmacy Solutions. The first, Dr. Mona Siddiqui, is senior vice president of clinical strategy and quality at Humana. Her background is in public service, especially with HHS and the Center for Medicaid and Medicare Innovation. The second is Dr. Scott Greenwell, senior vice president of pharmacy solutions at Humana, who played an integral role in launching Humana’s Medicare Part D program. The discussion is around innovation in service delivery both before, during, and after the pandemic.

Analyzing Trends to Improve Programs: Data-driven program design utilizing almost-real-time data from CMS or FDA can have an enormous impact on end users. Bringing together data assets from Humana’s insurance side, home segment, and pharmacy segment has provided insight into differing needs of pharmacy customers, most recently during the pandemic.

Social Determinants During the Pandemic: During Covid social determinants of health are of paramount interest. Humana focused on listening to customer needs, including food scarcity, loneliness, transportation access, early prescription refills, mail delivery, and allowing periodic lab requirements to be postponed.

Will Changes Made During the Pandemic Last?: You can’t put the genie back in the bottle. Consumers will expect changes like mail delivery to remain in place even after the pandemic is under control. Surprisingly, even seniors preferred an end-to-end digital experience; they are used to seamless digital experiences now because of entities like Amazon.

Meeting Consumer Expectations with Technology: Humana began in 2015 with the real-time benefit check transaction as an early transparent digital process. This was integrated into the physician’s existing workflow and the response was that this was just what had already been expected. Even those who have been uncomfortable with digital tools approve of them when the experience is frictionless for patients and providers.

Specialty Drugs in Disease-specific Clinical Initiatives: Where traditional rebate tools will not work, as with specialty drugs, Humana sometimes uses value-based contracting. The company also has a program called UM Ultra, which creates personalized utilization management, such as looking at dose optimization, so that patient value is balanced with drug cost.

Promoting Covid Testing: In addition to covering testing costs, Humana has also made at-home testing kits available. And it created a drive-thru PCR test partnership with Wal-Mart that delivers results digitally and refers out as well, when necessary. And, again, the purely digital process has proved more popular than the drive-thru process, counterintuitively for some.

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JC Scott speaks with Doug Long, Vice President of Industry Relations at IQVIA, about the impact of COVID-19 on the pharmaceutical market. Long discusses the data trends for pharmaceutical companies during COVID-19 and, most importantly, how these trends impact healthcare patients.

Prescription Stockpiling: With news of the impending pandemic, patients around the US began to stockpile 90-day prescriptions in March. As a consequence, the pharmaceutical marketplace experienced a major decrease in demand in the following two months. Long describes the effects of this “prescription rush” and subsequent demand decrease on the pharmaceutical industry.

Access Prescriptions and Shortages: JC and Long discuss methods by which patients are receiving their prescriptions during COVID-19. Mail-order and other socially distant methods (such as deliveries) have grown in popularity. Long also details how the pharmaceutical industry has responded to recent supply chain shortages. Overall, he is impressed by the resilience of the pharmaceutical supply chain (which includes manufacturing, PBMs, pharmacies, wholesalers, and logistics companies) during COVID-19.

Growth of TeleHealth: Long touches on the impact of telehealth on the healthcare marketplace and medical prescriptions. He notes the dramatic growth of telehealth in a matter of just a few months, and he believes that telehealth is here to stay. However, he cautions that telehealth may have a negative impact on prescription trends for patients.

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Host JC Scott speaks with Megan Hauck, a former Health Policy Advisor to President George W. Bush, Senator Mitch McConnell, and Chris Jennings, former Senior Advisor for Health Policy for both the Clinton and Obama Administrations. In this episode, Scott, Hauck, and Jennings discuss the election results, what a new president and Congress will mean for healthcare policies, and speculate how shifts in the House and Senate will impact the future of healthcare.

The failure of polling. The results of the election, specifically regarding the performance of Republicans in the House and Senate, were a big surprise to many. Hauck calls for polling to be modernized while Jennings argues that the media and its consumers over-utilize polling. With the massive turnout, the voters clearly called for collaboration in fighting Covid-19.

Policies the Trump Administration might push in these final weeks. Regarding healthcare, the administration is currently examining the Rebate Rule and a proposal to tie drug prices to an international benchmark. It’s normal for an administration to push out prioritized regulations in their last eight weeks. Technically, Congress can overturn them under the Congressional Review Act, but this can be an arduous process. Hauck points out that the Trump administration will prioritize its own policies over those that will help Congress in the long run, something that is unusual compared to previous presidents’ administrations.

Narrow majority chambers, will they come together for healthcare? Jennings suggests that there will be bipartisan interest in preventing future pandemics, once we have control over the virus. Until then, Covid-19 is expected to be the primary focus regarding healthcare. The pandemic has also exposed the shortcomings of the healthcare system and exacerbated Medicare solvency, leaving public healthcare and Medicare as the next big issues to tackle. President-elect Biden will likely address states who have not expanded Medicaid. Hauck and Jennings also discuss how Biden’s previous experience in the Senate will impact his ability to navigate Congress as President.

Refusal to transition. With President Trump refusing to concede, there is an unprecedented lack of communication between the Trump and Biden teams. This means that the incoming Biden administration does not have access to key departments and information for fighting Covid-19, including the distribution of vaccines and testing dynamics. Hauck and Jennings both share experiences of their duties when they worked during presidential transitions, agreeing that it’s a patriotic duty to assist the next team coming in and that the delays are inexcusable — but not insurmountable.

More elections to come, more predictions. Midterm elections are coming in 2022. With narrow majorities in both chambers, Hauck and Jennings offer their predictions for the House and Senate outcomes.

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Host JC Scott speaks with Amy Bricker, Senior Vice President of Health Services Supply Chain at Express Scripts and previous commissioner for MedPac. November is National Diabetes Month, and the discussion this week revolves around how PBMs help keep the costs of insulin down and improve patient care.

Getting Support for Diabetes in America

List prices for insulin have not gone down, leaving some diabetes patients with high costs for the live-saving medicine, either as high insurance co-pays or deductibles or the high cost of insulin itself. While there have been some improvements in delivery technology and formulations, Bricker points out that these innovations don’t justify the high prices pharmaceutical companies continue to charge. To some extent, the lack of competition in the market is causing this, which is why PBMs are so important.

How Express Scripts is Helping

Last year Express Scripts saw a 5% decrease in spending from those enrolled in their clinical solution, thanks in part to discounts but more critically through leveraging formularies, utilization, and diabetes care value program that ensures patients get complete care, communicated in ways that work best for them.

The Effects of Coupon and Discount Programs

Bricker argues that well-intentioned programs like 340B are out of control and no longer helping patients. She believes this and other coupon programs require major reform or even elimination, because they operate in the background and disrupt formularies.

CMS Part D Senior Savings Model

The Centers for Medicare & Medicaid Services established a voluntary Part D plan that limits insulin’s cost share to $35 a month per beneficiary. Approximately a third of Medicare beneficiaries are affected by diabetes and companies such as Express Scripts and Cigna will participate in this program. While Medicare Part D definitely needs reform, steps such as these are a great starting point and crucial to those within the program.

What Does the Future Look Like?

Bricker says we need to encourage manufacturers to lower prices, but that needs to be encouraged by legislation or regulation — while always keeping the patient top of mind. She advocates for Part D reform to establish more programs like the #35/month cost share.

You can subscribe to The Pharmacy Benefit on Spotify, Google Podcasts, Apple Podcasts, and all other major platforms.

Host JC Scott speaks with Mark Newsom, the principal and founder at Health Evaluations LLC, on the core role of Pharmacy Benefit Managers (PBMs). Newsom goes through the process PBMs take to get us, the consumers, the most effective medications for the lowest premiums. He also discusses PBMs and their role in conjunction with the other players in the industry. Some key points from the conversation include:

Why PBMs Exist And How Savings Are Generated For The Consumers: Newsom accentuates how PBMs’ role in doing the formulary is one of the biggest steps in reducing costs of prescriptions while also increasing the safety of the consumer. He also focuses on how negotiations between manufacturers and pharmacies is a key area for lowering prices. These savings from each individual step help consumers save 40-50% on their annual costs in the form of lower premiums.

A Breakdown Of Where The Money Flows And The Thin Line Of Profit PBMs Tread On: JC Scott breaks down the purchasing dollar and where it goes within the pharmaceutical industry and questions Newsom about the low profit margins of PBMs. Newsom explains how much money is saved for every dollar spent on PBMs, and how even a low percentage of the total money involving pharmaceutical drugs goes a long way when there are billions of prescriptions every year.

What Actions Undermine The Work Of PBMs: Newsom discusses how everyone wanting everything hurts the effectiveness of PBMs working to get people quality prescriptions at lower costs. With individual preferences and politics getting involved, PBMs must work around these obstacles in order to provide the best service they can.

You can subscribe to The Pharmacy Benefit on Spotify, Google Podcasts, Apple Podcasts, and all other major platforms.