Despite rising costs, plan sponsors are committed to providing prescription benefits to their members.
A new in-depth survey on the state of pharmacy benefit management finds most sponsors are looking at a number of ways to control costs, but few have considered dropping coverage entirely.
Still, plan sponsors are facing considerable challenges in mitigating rising benefits costs. More than 75 percent of plan sponsors say behavior-driven conditions are the greatest contributors to plan costs, according to the survey, "9 Leading Trends in Rx Plan Management" from Express Scripts.
The survey is a poll of benefit managers from 318 organizations representing more than 9 million covered lives.
The following pages describe the trends found in the survey >
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- Member health decisions now No. 1 cost issue
- Plan sponsors look to online tools and mobile apps to lower costs
- Health reform raises questions about future coverage options
- EGWPs may soon outnumber RDS plans
- CDH plans gaining momentum...again
- Mail strategies growing and delivering results
- Comprehensive management key to mitigating specialty trend
- Drug coupons raise cost concerns
- Plan sponsors embrace data-driven pharmacy care
1. Member health decisions now No. 1 cost issue
In 2011, nonadherence led to more than $317 billion of avoidable medical costs, according to Express Scripts. Three-quarters of plan sponsors believe the greatest influence on health care costs is behavior-driven, and that member decisions have three times the impact on costs as health reform, new medications, biosimilars and electronic medical records combined.
For the first time in the survey's history, wellness programs were cited as the single most effective measure to control overall health care costs, garnering 25 percent of the responses in a field of 10 choices. While only 58 percent report that they currently use a wellness plan (and only 26 percent of union respondents), 81 percent say they intend to offer one in the next two years.
The survey states that integrated pharmacy/medical data is "likely to play an increasing role in identifying members at risk, and coordinating efforts with disease management and wellness vendors. At least three-quarters of respondents say they intend to employ integrated data programs to support these initiatives within the next two years."
Strategies that have worked to influence member behavior:
- Offering financial incentives for participation - 47 percent
- Using penalties or disincentives to discourage certain behaviors (e.g., higher premiums for smokers) - 18 percent
- Offering financial incentives for preferred outcomes (e.g., weight loss) - 11 percent
- Other - 10 percent
- None/have not used any - 9 percent
- Offering nonfinancial incentives (giveaways or recognition) for participation - 6 percent
2. Plan sponsors look to online tools and mobile apps to lower costs
Member communications is the most popular measure to promote the cost-effective use of prescription drugs, according to Express Scripts. "Cost share that favors generics and mail is the only other measure that is used as extensively."
However, "Only 3 percent of plan sponsors believe that member communications are among the most effective strategies to encourage use of mail and generics. This may be why 44 percent of sponsors cite 'the ability to engage members to participate in measures that reduce costs' as one of the two greatest challenges in managing their benefit."
Plan sponsors have reportedly been adopting new media tools to provide members with more personalized health care purchasing information. Seventy percent report they "currently use online tools or mobile apps to help members make more cost-effective healthcare decisions, with 84 percent saying they are likely to use such tools in the next two years."
3. Health reform raises questions about future coverage options
Express Scripts survey authors admit they expected health reform to dominate the agenda for this year's PBM study. However, that was not the case - at least when it came to prescription plan management.
"Only 5 percent of respondents consider the impact of healthcare reform to be their greatest challenge, with another 8 percent considering it to be their second greatest challenge.
"Our survey indicates that healthcare reform is not likely to fundamentally change how, and whether, plan sponsors cover their current members. In fact, only 42 percent of plan sponsors report that they have completed a formal analysis of alternate healthcare coverage approaches...Only 22 percent reported that dropping coverage was an option they even considered."
Plan sponsors are evaluating alternative provider/payment strategies. Tiered or narrower networks (i.e., where providers are placed into different cost-share structures or the network includes a smaller number of providers) topped the list.
4. EGWPs may soon outnumber RDS plans
Plan sponsors say they're confused about retiree benefit options.
According to the survey, "The recent legislation eliminates a key tax advantage for RDS plans in 2013, effectively raising costs for taxable entities. As an apparent result, there has been a dramatic shift away from RDS plans. While 78 percent of all sponsors say they currently cover retirees through an RDS plan, only 53 percent say they intend to keep them. Among for-profit sponsors, 83 percent currently have RDS plans. Only 45 percent plan to retain them."
While interest in RDS (retired drug subsidy) is declining, interest in EGWPs (employer group waiver plans) is on the rise. "While only 10 percent currently provide coverage through an EGWP, 53 percent of all plan sponsors are considering it, including 59 percent of the for-profits."
Twenty-eight percent of plan sponsors are considering transferring members to a Prescription Drug Plan and subsidizing coverage (up from the 8 percent that currently do so).
5. CDH plans gaining momentum...again
Though the last report from Express Scripts stated consumer-driven health care growth was fairly flat, CDH plans have "recaptured the momentum of their early days."
According to the Kaiser Family Foundation 2011 Employer Health Benefit Survey and the 2012 Mercer National Survey of Employer-sponsored plans, which are cited in the Express Scripts report, the share of covered workers enrolled in high deductible plans with a savings option doubled from 8 percent in 2009 to 17 percent in 2011. The Mercer survey found that employers with more than 500 employees had a sharp increase in CDH plan offerings, from 23 percent in 2010 to 32 percent in 2011.
"We experienced this change firsthand with 40 percent growth in CDH plan enrollment in 2011. Our annual customer survey noted that overall satisfaction with CDH plans continues to be greater than 90 percent, and that one in three clients will offer a CDH plan in the future."
CDH ranked second behind wellness strategies on the list of measures most effective in controlling overall health care costs.
6. Mail strategies growing and delivering results
Nine in 10 respondents to the Express Scripts survey agree the mail channel has "clear cost and convenience advantages over the retail channel."
"The mail channel is perceived to have an advantage over retail in maximizing use of generics (55 to 9 percent), improving adherence (41 to 21 percent), reviewing prescriptions (41 to 23 percent), and dispensing safely (35 to 7 percent). With such a broad spectrum of cost and care advantages, it comes as no surprise that plan sponsors are aggressively promoting the mail channel, using every tool at their disposal."
7. Comprehensive management key to mitigating specialty trend
The increase in overall drug cost is being driven by specialty spending, according to Express Scripts. Thirty-six percent of plan sponsors cited “the rising utilization and cost of specialty medications” as the greatest concern in managing their prescription plan - and the larger the plan, the greater the concern. "Fifty-eight percent of plan sponsors with over 25,000 members cite rising specialty costs as their greatest concern, compared to just 24 percent of those with fewer than 5,000 members."
Larger companies are trying to combat this concern by adding preferred and step-therapy rules.
While there are differences in the strategies currently used, plan sponsors of every type and size are in near universal agreement on two points:
1. They intend to increase usage of every named cost-control strategy over current levels. (See chart below.)
2. They believe that a PBM with comprehensive services (specialty and nonspecialty) is better equipped to manage the cost and usage of specialty drugs, regardless of whether they are billed under the pharmacy or medical benefit. PBMs are preferred to specialty-only vendors 75 percent to 6 percent, and they’re seen as superior in providing consistency of coverage/therapy and visibility, as well as promoting adherence and safety.
8. Drug coupons raise cost concerns
It used to be pharmaceutical advertising that suppressed generic utilization and increased costs.
Now, Express Scripts cites data from the Pharmaceutical Management Care Association that co-payment coupon programs will increase 10-year prescription drug costs by $32 billion for employers, unions, and other plan sponsors if current trends continue.
Copay coupon programs are designed to increase the use of brand medications by offering patients a discount coupon. "Some employers and health plans believe that coupon programs enrich manufacturers by driving patients toward more expensive drugs. Critics characterize the strategy as a campaign to maximize profits from aging blockbusters."
9. Plan sponsors embrace data-driven pharmacy care
"Plan sponsors overwhelmingly support the application of evidence-based medical care to pharmacy. Ninety-seven percent of sponsors stated that it was at least somewhat important to incorporate research and evidence-based medicine into pharmacy care, including the 41 percent who thought it extremely important."
More than half of all respondents now incorporate integrated pharmacy data in at least four ways, according to Express Scripts: to identify members at risk (63 percent), to provide better case management (57 percent), to enable coordination of care with disease management vendors (57 percent), and to allow for better decision making (56 percent).