Pharmacy Plan Management:
More Critical Than Ever

Author: Dea Belazi, president and CEO, AscellaHealth

A plethora of regulatory and business issues are raining down on virtually every segment of the healthcare industry. But changes in managing the drug spend are especially troublesome, particularly with the rising cost of prescription drugs and the staggering high costs of specialty Rx.

Proposed government regulations to eliminate rebates to intermediaries, coupled with payer acquisition of companies to manage the drug spend or create new internal capabilities to lower costs, have resulted in even greater challenges.

Add in a surge of finger-pointing, and the U.S. healthcare system faces a slippery slope to make medications – specialty pharmaceuticals in particular -- more accessible and affordable for patients.

By addressing the specific challenges that confront payers, patients and pharmacy health plans, all stakeholders can work toward successfully resolving these critical issues that impact patient care.

A new federal rule removes safe harbor protections under the federal anti-kickback statute for rebates paid by drug manufacturers to intermediaries, Part D plans and Medicaid managed care organizations.

In response, a number of healthcare leaders have voiced concern about the proposed rule: America’s Health Insurance Plans (AHIP) has accused the U.S. Department of Health and Human Services (HHS) of unfairly blaming insurance providers and their Pharmacy Plan Managers for the health system’s current high prices. At the same time, CVS blames the pharmaceutical manufacturers for high drug costs. In fact, CVS credits the intermediaries for serving as the last line of defense for the patient.

A majority of rebates and discounts are passed back to patients, according to insurance executives, and rebates reduce costs for patients and insurers. Without these cash flows, it is more likely that drug costs for patients and insurers will go up, rather than down.

Anthem Launches its Own Drug Management Plan

Anthem, Inc. recently revealed an early launch for IngenioRx, its new Pharmacy Plan Management company. Ranked in the top five health insurance payers in the nation, Anthem’s announcement that it will opt for an early exit to the relationship with Express Scripts, have a temporary home with CVS Health, and then build its own capabilities demonstrate an important point: the marketplace demands the function historically filled by intermediaries, such as pharmacy benefit managers.

Reduced market concentration that results from this Anthem transaction should be good for payers and patients alike. The emergence of new intermediaries, whether inside or outside an insurer, is likely to drive new solutions and the development of new models.

The bottom line is that drug managers play an important role in the pharmaceutical supply chain and are positioned to protect consumers and save them out-of-pocket costs.

Specialty Drugs

Specialty drugs are seeing climbing market share. As a drug class that is higher in cost, specialty drugs are critical for patients. These drugs target, for example, orphan diseases (conditions that affect fewer than 200,000 people nationwide) or conditions such as Hepatitis C.

The costs associated with these drugs are extraordinary, with estimates that specialty pharmacy costs may account for 40 percent of total drug spending by 2020.

In this environment, the drug plans staffed by professionals with specialized drug care management skills are a sustainable model – whatever regulatory or competitive climate prevails.

Ascella: Best-in-Class Pharmacy Plan Management

Given the changes ahead, the need for greater clinical coordination with the pharmacist has become an imperative. This is where Ascella has excelled.

We have a proven track record for curbing costs for payers and patients and reengineering the pricing model, particularly with high-cost specialty drugs.

Our value-added and personalized services include high quality prescription drug management services along with other customizable services. These include carved-out specialty pharmacy services and cost-savings discount programs through our unique and proprietary service. Our resources extend discounts on prescription medications to customers -- more than any other intermediary company in the industry.

We help improve care coordination and patient outcomes because we are always in the right place at the right time -- creating custom benefit designs, maximizing benefit plans and reducing costs.