Analysis

It’s time for our annual analysis of the Kaiser/HRET 2016 Employer Health Benefits Survey, which you can read online for free. The survey delves into employer-sponsored health coverage at 2,000 companies. In the charts below, I summarize employers’ 2016 pharmacy benefits by examining (1) cost-sharing tier structures, (2), average copayments, by formulary tier, and (3) type of cost-sharing (coinsurance and copayment).

This year’s results highlight the growing discrepancy between diseases that can be treated with traditional drugs and those that require specialty drugs. Traditional therapy classes that treat larger patient populations have multiple generic drug options and fixed dollar copayments.

By contrast, employers continue shifting the cost of specialty prescriptions to their beneficiaries. Patients taking specialty drugs face economically-debilitating coinsurance—in some cases with no limit on out-of-pocket expenses. These benefit designs essentially discriminate against the very few patients undergoing intensive therapies for such chronic, complex illnesses as cancer, rheumatoid arthritis, multiple sclerosis, and HIV. But isn’t insurance supposed to help when things go really wrong?

Read on for full details along with some lovely tiers/tears puns.

ACO Population Health Congress
December 8-9, 2016 | Tampa, FL
www.cbinet.com/ACO

CBI’s ACO Population Health Congress conference offers payers and providers the opportunity to discover solutions for day-to-day challenges, improve the health of members and enhance models to quantify improvement and outcomes. As the ACO model shifts from fee-for-service to value-based care models, it is critical for ACOs to understand population health management and value-based networks in order to improve coordination of care and health outcomes. Discover tactical strategies, gain policy insights and benchmark with industry experts to develop solutions to improve population health and achieve operational excellence.

Gain Comprehensive Insights on:

• Implications of MACRA Proposed Rule on ACO Operations
• Patient registry refinement and clinical integration hierarchies to successfully define populations and accurately report quality measures
• Post-acute, coordinated care initiatives to reduce hospital admissions, readmission, ED utilization and variations in care
• Proactive outreach to noncompliant patients and automated patient outreach programs to decrease cost of care downstream
• New methods for reviewing contracts to assist in quantifying risk and determining potential benefits of switching ACO models
• Best practices to enhance patient experience and improve outcomes through patient engagement and coordinated care

Case Study Spotlight:

• Leaving the Next Generation ACO Model – Financial and Operational Implications
• Remove Barriers and Reduce Unnecessary Hospital Utilization to Improve Beneficiary Health

Visit www.cbinet.com/ACO for more information. Drug Channels readers will save $200 off the standard registration rate when they use discount code QZM698.*

*Cannot be combined with other offers or used towards a current registration. Cannot be combined with special category rates. Other restrictions may apply.

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The content of Sponsored Posts does not necessarily reflect the views of Pembroke Consulting, Inc., Drug Channels, or any of its employees.

Redirecting to 2021 update

Please see the updated article from 2021: Follow the Vial: The Buy-and-Bill System for Distributing and Reimbursing Provider-Administered Outpatient Drugs

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By reader request, below is a channel flow chart illustrating the buy-and-bill process for provider-administered drugs. It complements Follow the Dollar: The U.S. Pharmacy Distribution and Reimbursement System, which focuses on patient-administered outpatient drugs.

This post is adapted from Section 3.1.2. of our The 2016–17 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors. Friendly reminder: Discounted pricing for the report ends today!

Now, here’s something I hope you’ll really like!

I recently collaborated with Julie Appleby at Kaiser Health News (KHN) to explain the flow of funds between a pharmaceutical manufacturer and the patient.

The resulting graphic (below) uses a typical brand-name prescription to show the profits earned by key drug channel participants: manufacturers, pharmacy benefit managers (PBMs), wholesalers, and pharmacies. It also illustrates the payer’s net costs and manufacturer’s net price.

KHN’s well-produced design complements the less pretty Rube Goldberg diagram that I shared in Follow the Dollar: The U.S. Pharmacy Distribution and Reimbursement System. The KHN chart may look like a PTCTU*, but it will help you understand the method to the madness.

CBI’s Specialty Product Data Strategies
December 14, 2016 | Philadelphia, PA
www.cbinet.com/specialtydata

Have you seen the agenda for the Specialty Product Data Strategies meeting yet? Being held on December 14th in Philadelphia, this is the pharma/bio industry’s only data summit devoted to specialty product returns with cutting-edge case studies and forward thinking presentations.

Featuring trailblazing insights from executives representing AstraZeneca, Bayer Healthcare Pharma, Biogen, Blue Fin Group, Therigy and ValueCentric, this meeting is poised to showcase how to strategically contract, analyze and utilize specialty data to illustrate value.

Topics at a Glance:

• Contracting Considerations – Acquisition and Collection of Specialty Product Data
• Decision-Making Journey for Coverage of Specialty Products
• Analyzing Specialty Pharmacy Data Sets
• Understanding FMV – Industry’s Going Rate for Specialty Product Data
• Integrated Delivery Network (IDN) – Specialty Pharmacy’s Role in the Delivery and Documentation of Improved Patient Outcomes
• Emergence of Specialty Pharmacy Data within Integrated Healthcare Systems – A Patient-Centered Model
• Tap Specialty Product Data to Propel Commercial Success and Enhance the Patient Experience

For more information, download the complete agenda. You can register online at www.cbinet.com/specialtydata Drug Channels readers will save $200 off of the standard registration rate when they use discount code JHQ838.*

*Cannot be combined with other offers or used towards a current registration. Cannot be combined with special category rates. Other restrictions may apply.

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The content of Sponsored Posts does not necessarily reflect the views of Pembroke Consulting, Inc., Drug Channels, or any of its employees.

ICYMI: Walgreens Boots Alliance (WBA) has been lining up a broad range of preferred network agreements. In its latest move, Walgreens will unexpectedly displace CVS this December in the retail network for TRICARE, the healthcare program for uniformed service members, retirees, and their families. Click here to read the announcement. I provide additional details below.

TRICARE is the latest in a string of deals engineered by Stefano Pessina, our global channels overlord and executive vice chairman and chief executive officer of WBA. In case you’ve lost track, I summarize Walgreens’ recent preferred pharmacy arrangements with Express Scripts, OptumRx, Prime Therapeutics, UnitedHealthcare, and Valeant.

WBA appears to be sacrificing profits for volume. The scope and diversity of the deals, however, clearly reflects WBA’s previously articulated industry-wide partnering strategy. It also provides an intriguing contrast with CVS Health’s closed system approach.

Read on and be impressed.

The Centers for Medicare & Medicaid Services (CMS) just released the initial data on the 2017 Medicare Part D plans. Our exclusive analysis reveals that preferred cost sharing pharmacy networks are back.

For 2017, 85% of Medicare Part D regional prescription drug plans (PDP) will have a preferred network. That’s comparable to the figures from the past three years.

Below, I provide historical data on preferred networks’ growth and then identify 2017’s top plans. The two largest companies—UnitedHealthcare and Humana—offer only preferred networks for 2017. Both companies are also offering co-branded plans with retail chains: United Healthcare with Walgreens, and Humana with Walmart.

Such narrow pharmacy networks—either preferred or limited models—are now an unstoppable and widely accepted element of benefit design. Pharmacies will continue to see their prescription profit margins terminated. In a future post, I’ll be back to examine which chains and independents are participating in the preferred networks.

CBI’s 12th Annual Life Sciences Trade and Channel Strategies Conference
December 13-14, 2016 | Philadelphia, PA

It’s a wild and crazy time in the drug channel. Get ready for 2017 by joining me at CBI’s 12th Trade and Channel Strategies conference, being held this December in beautiful Philadelphia, PA.

I will kick things off with a keynote address called Drug Channels Update—Things to Watch in 2017. I’ll update everyone on hot topics and identify key strategic issues for the year ahead. As usual, we’ll end the first day with the renowned Trade Throwdown: Battle of the Experts. REMINDER: This is the only CBI event where I present!

CBI’s annual event is one of the industry’s premier events focused on bio/pharma trade, channel, and key account management. Use discount code PKJ933 to save $400.

Read on for more details from CBI. Or just click here to register now. Hope to see you in December!

• Click here to download a free report overview (including the Table of Contents and a List of Exhibits)

• Click here to read the press release (which highlights some key findings about revenues, specialty drugs, and biosimilars)

We’re offering special discounted pricing if you order before October 14, 2016!

This report offers the most complete examination of the pharmaceutical distribution industry’s economics, market structure, growth rates, forces of change, and interactions with the U.S. healthcare system.

See below for more info and some behind-the-scenes tidbits. Happy reading!

Eyeforpharma’s Real World Evidence & Market Access USA 2016 Summit
November 9-10, 2016 | Philadelphia

Innovative drugs, with ever-improving outcomes, are the future of any pharma company.

But for most of us, our ability to form partnerships and develop new value propositions in a patient-centric world are now just as important – if not more so. With external stakeholder pressures building, the focus has shifted to developing key partnerships in a patient-centric world.

The transition from volume to value is well underway. Eyeforpharma’s Real World Evidence & Market Access USA 2016 Summit is designed around this transition. Companies seek to find, create, and deliver value so that pharma, payers, providers and ultimately patients can benefit. Of course, it all starts with good leadership, and good evidence – the two pillars of Eyeforpharma’s Real World Evidence & Market Access USA 2016 Summit, now in its 6th year.

With two targeted tracks – dedicated to high-level managed markets, pricing & HEOR strategy, and next-generation real world data technologies – this annual gathering aims to give experts a platform to shape the future of access in pharma, bringing everyone to the table from patients to payers and providers. Exclusive panel debates will bring pharma face-to-face with its key stakeholders, while insightful case studies from Lilly, Novartis, GSK, Pfizer and BMS will ensure attendees go back to their jobs with a deeper, more intelligent understanding of the solutions to the industry’s biggest challenges.

Save a place at this unmissable summit for you and your team today. Use discount code 4639CHANNELS for a $300 discount on registration.

Eyeforpharma looks forward to seeing you in Philly this November!

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The content of Sponsored Posts does not necessarily reflect the views of Pembroke Consulting, Inc., Drug Channels, or any of its employees.