If nothing else, the 2008/2009 Novartis Pharmacy Benefit Report finds just how completely managed care is, well, managed. Patients and physicians alike must run an impressive gantlet of requirements as the managed care organizations (MCOs) try to exert more control over both drug utilization and health outcomes through their many policies.
The Novartis study combines a survey of MCO medical directors, conducted in early 2008, with data from Wolters Kluwer Health’s Source Pharmaceutical Audit Suite (PHAST) database, which collects prescription sales data from some 80% of retail outlets. The survey and data examine trends and policies during calendar year 2007, with forecasts or polls of policies that were being planned for 2008 and this year.
The report divides the MCO landscape into three categories: commercial/group plans (including HMOs, PPOs and employer plans) covering some 91.7 million insureds; managed Medicaid, covering 42.6 million (including dual eligibles, who also qualify for Medicare coverage); and the 23.9 million seniors who had been enrolled in Medicare Part D plans (of which there are two types: Medicare Advantage prescription drug plans [MA-PDs] and prescription drug plans [PDPs]).
Overall, the report notes that plan costs were rising, generic utilization is on the increase, and the number of three-, four- and even five-tier plans were increasing—all trends not unique to MCOs. Tiered plans put more costs onto the shoulders of beneficiaries; a typical arrangement is out-of-pocket charges up to $100 or so of a prescription cost, with costs above that level covered. Tier 4 and 5 are both higher-priced drugs and higher co-pays or minimums. Choosing generics lowers all these costs, offering zero co-pays in some instances.
Other MCO controls are requirements for prior authorization (the better to control drug utilization) and “NDC blocks” that restrict coverage on new drugs that have yet to be reviewed by the Pharmacy and Therapeutics (P&T) committees of MCOs. Yet another control is “step care protocols,” which require one medication to be used before another (usually more expensive) one is prescribed.
Specialty pharmacy: moving fast
One of the fastest-growing trends in MCO drug plan policies is to use specialty pharmacies to dispense prescriptions for newer or higher-priced specialty drugs. In the survey of MCO directors, Novartis found that there are a surprising long list of issues surrounding specialty pharmaceuticals and retail dispensers (Table). One notable item on that list: “delivery channel management and timeliness of delivery,” which indicates that specialty pharmacies are having a harder time of keeping drugs in stock, and MCOs are having a harder time properly accounting for their use. (Note also the issue of “limited distribution,” which probably comes about from the exclusive specialty pharmacy agreements that some manufacturers have with some pharmacies.)
Establishing a specialty drug tier is especially prevalent among Medicare Part D programs (both MA-PDs and PDPs) where nearly two-thirds of plans had such a tier in 2007; by comparison, only 26.1% of commercial/group plans had one.
Medication therapy management on the rise
MTM programs, which provide for face-to-face or other types of counseling of patients, were funded by the legislation that established Medicare Part D; MTM programs can also be a part of non-governmental plans. Locating, providing services, capturing medical data and assessing outcomes are all challenges reported by MCO directors. Healthcare professionals providing the MTM services include MCO staff pharmacists, nurses, and consulting or retail pharmacists.
The report is available from Novartis’ East Hanover, NJ, location. PC