Coverage and Payment for Biotechnology and Medical Devices
Academy Health June 4, 2007
Thomas Weisman, MD, MBA Ohio Medical Director Anthem Blue Cross and Blue Shield
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Agenda
• P & T Process
• Cost of Care Committees
• Value Chain • Transparency
• Examples • Herceptin • Specialty Pharmacy
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P & T Process
• Clinical Review Committee (CRC)
• Majority external representation • Assessment of efficacy only • Superior
• Equivalent
• Inferior
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P & T Process
• Value Added Committee (VAC)
• Internal representatives • Cannot disadvantage superior medication • Within restrictions, business needs rule
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Cost of Care Committees
• Provider Relations
• Medical Directors • Actuaries • Support areas • PBM • Behavioral Health • Operations
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Cost of Care Committees
• State level (OH)
• Central Zone (OH, IN, KY, MO, WI) • Enterprise
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Value Chain
• Deconstruct and examine each
step/activity • Is this an activity a customer would pay extra for? • Internal activities
• Device/Pharmaceutical
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Transparency
• Cost and (limited) quality information • 38 elective services
• Cost • Event or “shoebox” methodology • Results presented in “bands” • Can see impact on member responsibility
• Quality • Volume of cases • Access to Subimo information
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Transparency
•Consumer Directed Health Plans (CDHP) • Increasing consumer cost sharing • Increasing consumer engagement • Increasing market forces
• Increasing consumer focus on value 9 chain
Herceptin
• Monoclonal antibody
• Useful in HER2 positive breast cancer
• Useless in HER2 negative breast cancer
• Cardiotoxic
• Expensive
• Weekly infusions, either alone or in combination chemo regimens
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Herceptin
• • •
•
J9355 Summary by Financial Arrangement (OH, IN, KY, MO, WI) Total After rem Medicare claims
After rem NASCO ASO
23,618,980 18,668,905
8,024,165
•
Tot allowed amt for Fully Ins (after rem other ASO) 5,609,691
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Herceptin
United Health Care Pilot (anecdotal information) demonstrated that 1112% of women receiving Herceptin did not have documentation of positive HER2 gene test
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Herceptin Proposal
• • Activate CG-DRUG-02 as of 7/30/2007—no grandfathering Require documentation of positive HER2 and attestation of normal cardiac function
• Letter to all oncologists
•
•
Separate letter to oncologists with members on Herceptin
Rapid update
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Herceptin Proposal
•
•
Create Provider Tool and Desktop
Training for MD’s and for RN’s in Pre-D, Med Review and Precert
• •
•
Provider Relations, Med Review, Pre-D and Specialty Rx sign-on Track PMPM (absolute and trend) compared to states not managing Herceptin
Track denial rates
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Specialty Pharmacy
• • • Pilot in California, Colorado and Nevada 84 (soon 87) medications require guidelinebased authorization for payment Some medications (by volume, 5% of above) will require purchase from PrecisionRx Specialty Services including: • Hemophilia factors • TNF inhibitors ( but not Remicade) • Synagis • Somatotropins and Gonadotropins • Hyaluronic acid derivatives • Interferons 15 • Enzyme replacement products
Conclusion
• Health plan decision-making will be driven by concerns for: • Affordability • Patient safety • Value
Transparency and Consumer engagement will reinforce above trends
•
•
Initial efforts focused on newer agents and “low hanging fruit”
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Trademark Information
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In most of Missouri: RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In most of Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association
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