Radar on Drug Benefits

Large insurer-affiliated PBMs saw strong results for the third quarter of 2020, in several cases driving revenues for parent companies that are grappling with various disruptive effects of the coronavirus pandemic.

In earnings conference calls over the last month, company executives from CVS Health Corp., Cigna Corp. and Anthem, Inc., generally touted performance from their PBMs. Both Cigna and CVS credited their PBM business segments with driving strong third-quarter earnings for their companies. UnitedHealth Group, however, reported a 2% year-over-year decline in PBM earnings, which the company attributed to a pandemic-related drop-off in prescription volume.

As is the case for other flavors of health care reform, President-elect Joe Biden’s chance of passing substantial, transformative drug-pricing legislation is now highly dependent upon whether Democrats can eke out a majority in the Senate. While that question won’t be resolved until Georgia completes runoff elections in January, industry observers point out that there are ways that a Biden administration can address drug pricing through its regulatory authority — plus areas where even a split Congress might have enough common ground to pass legislation.

“A president can do a lot even with a divided Congress,” says Stephanie Kennan, a member of McGuireWoods Consulting’s federal public affairs group and former senior health policy adviser to Sen. Ron Wyden (D-Ore.) “Part of how well something gets done…depends upon the skills of the president or those negotiating for him. With Biden perhaps having a better understanding of the Senate, having come from the Senate, [that] might help him.”

In response to rising drug prices, some states have launched prescription drug review boards designed to make medicines more affordable. So far, the boards control prices mainly for states’ Medicaid and state employee plans, but some states are considering whether to set up panels that would also work to set upper payment limits for prescription drugs in commercial insurance.

A new report by professional services firm Manatt found that 17 states so far have implemented or introduced legislation for boards that exercise some influence on drug prices, primarily in the realm of plans controlled by state governments — state Medicaid plans and commercial plans in which the state government is the plan sponsor. The report found that six states — Maine, Maryland, Massachusetts, New Hampshire, New York and Ohio — have such boards in place.

✦ HHS and the Dept. of Defense reached a deal with CVS Health Corp. and Walgreen Co. to provide and administer COVID-19 vaccines to residents of long-term care facilities (LTCF) nationwide, with no out-of-pocket costs for patients, once they become available. The goal of the partnership is to “minimize the burden” on LTCF sites and jurisdictional health departments regarding vaccine handling, administration and fulfilling reporting requirements, HHS said in an Oct. 16 press release. In its own press release, CVS said it “has the experience and expertise to play a vital role in the COVID-19 vaccination effort,” noting that it’s now administered more than 5 million COVID-19 tests since the start of the pandemic. Read more at https://bit.ly/3jhCsTS.

✦ Highmark Inc. says it has been able to improve safety and reduce costs for patients with diabetes through “an innovative process that identifies opportunities to discontinue clinically ineffective prescriptions and flags dangerous medication combinations.” The Pittsburgh-based insurer touted its model, which “combines medical and pharmacy data and partners with primary care physicians to improve diabetes medication management,” at the Academy of Managed Care Pharmacy Nexus 2020 Virtual Conference on Oct. 19. The program is available to practices that participate in Highmark’s True Performance value-based reimbursement initiative. Read more about Highmark’s diabetes program at https://bit.ly/2FRiim8.

Employer-sponsored plans have “increasingly complex” prescription drug cost-sharing arrangements, according to the Kaiser Family Foundation’s (KFF) 2020 Employer Health Benefits Survey. But one expert says that plan sponsors and payers can help members manage the cost burden of prescription drugs by making more pricing and rebate data easily available to consumers.

The KFF survey found that the number of covered workers with tiered cost sharing for prescription drugs remained stable, with 89% of workers in a tiered cost-sharing plan in 2020, compared with 91% in 2019.