2016 OptumRx Trend Insights

Transcription

1 2016 OptumRx Trend Insights

2 TREND SUMMARY Overall trend summary This report offers our perspective of the forces driving trend and spending for 2015 vs We define trend as growth in year-over-year spending for our overall book-of-business. The headline net trend figure of 2.8% is the combined average for both traditional and specialty drugs, net of any rebates. Inflation was the biggest trend driver for both drug classes, with a net impact of 6.0%. Aggregate utilization increased slightly (less than 1%), but OptumRx trend management efforts contributed to an overall reduction of 4.1%. 2.8% OVERALL TREND 0.9% TRADITIONAL TREND 13.2% SPECIALTY TREND We know that our clients want to know specifically about themselves: What s driving my trend and what can I do about it? We always look forward to having those one-to-one conversations. But our clients also want to understand how they compare. Where do they stand against our book-of-business, as well as against different markets? These benchmark results can help identify best-in-class strategies and solutions. Note: The trend statistics shown in this report are true aggregate numbers. They are not dependent on having a predetermined group of management strategies in place. Scope This analysis is based on our carve-out commercial, and carve-in ASO commercial book-of-business. This article reflects claims experience for the period between January-November 2015 vs. January-November Overall trend (2.8%) is based on post-rebate data. All other metrics reflect pre-rebate figures. OptumRx 2016 Trend Insights 1

3 TREND SUMMARY What is happening in the industry at large? In order to place the OptumRx experience in context, let s begin by reviewing some industry-level figures. OptumRx participated in a recent survey of managed care organizations, health insurers, pharmacy benefit managers (PBMs) and third party administrators nearly 100 benefits payers in all. 1 For employer groups nationwide: Prescription drug costs continue to increase at double-digit rates, well in excess of costs for medical plans. 1 OptumRx 2016 main trend drivers Combined (traditional and specialty) prescription drug costs rose 11.3% in 2016 for active employees and retirees under age Specialty drug/biotech medications increased at a much higher rate, 18.9%. 1 OptumRx-specific results 6% 4.1% Increased reference prices (inflation) OptumRx trend management While OptumRx participated in the survey, OptumRx clients, on average*, saw much better results: Combined (traditional and specialty) prescription drug costs: 2.8% Stand-alone traditional drugs: 0.9% Specialty trend: 13.2% Trend management results: 4.1% OptumRx trend management activities are critical to helping our clients achieve their benefit goals. Of course, strategies will vary, since each plan sponsor has a unique set of goals and cost drivers. Turn to pages for a summary of our trend strategies. Our clients employ a variety of active programs and strategies to improve care and reduce costs. Our programs help manage specialty medications, drive generic and preferred brand utilization and manage the supply chain for ingredient cost savings through improved pricing. Clients can also take advantage of price protection, rebate contracts, and customized plan design advice. *These are average results and are not guaranteed. Client experience will vary depending on plan design, utilization, demographics and other variables. OptumRx 2016 Trend Insights 2

4 SPECIALTY TREND Specialty trend As they have for the past several years, specialty medications continue to be the principal driver of overall gross trend. These high-cost drugs account for 34.4% of the pharmacy spend, up from 31.8% in Specifically, specialty drug costs can be attributed to three main drivers: 13.2% SPECIALTY TREND 10.0% inflation The most significant driver, led by considerable price increases for chronic inflammatory, multiple sclerosis, and HIV medications. Specialty drugs account for 35% of all prescription drug spending. 1 But less than 1% of all medications are specialty drugs % utilization Increased moderately for specialty medications. 1.7% drug mix A mitigating factor as less costly drugs were utilized, due partially to the decrease in use and expenditures for hepatitis C medications, as well as increased use of HIV medications, which cost much less than most specialty drugs. OptumRx 2016 Trend Insights 3

5 SPECIALTY TREND Top 5 specialty classes by expenditure and trend Inflation was the most significant driver for specialty medications, led by chronic inflammatory, multiple sclerosis, and HIV. Utilization increased moderately: a 4.9% increase. Shifting the drug mix to less costly drugs helped, especially for hepatitis C and HIV medications. Mixed results show increases and decreases: Specialty medications are responsible for 88% of overall gross trend +33.2% trend +7.9% trend +20.1% trend 1 Chronic Inflammatory 2 Multiple Sclerosis 3 Oncology (cancer) +20.2% trend 32.4% trend 4 HIV 5 Hepatitis C OptumRx 2016 Trend Insights 4

6 SPECIALTY TREND Chronic inflammatory summary 88% claims 91% costs Over 2015, the proportion grew by 8.1% of overall pharmacy spending represented by specialty medications 33.2% total specialty trend There are many inflammatory conditions, including rheumatoid arthritis, plaque psoriasis, ulcerative colitis, and Crohn s disease. This helps to explain the overall cost as a class. In addition, high inflation and increased utilization pushed chronic inflammatory conditions to the top in overall spending, 29.5%, plus the highest PMPM increase of any class. Some of the most-used drugs in the class are high-cost biologics: Humira and Enbrel. Recent hopes for cheaper biosimilar competitors have dimmed. While a biosimilar to Humira has won FDA approval, it may not be marketed until 2018, due to costly patent litigation. Read more here. Oncology (cancer) summary 20.1% total specialty trend The oncology class includes hundreds of different cancer types. Together, these ranked as the 3rd highest spending category at 13.1% and saw the 2nd highest PMPM increase. Primarily, these increases were driven by expensive new therapies. Seven of the top 10 drugs by market share averaged over $7,000 per claim. Ibrance ($9,000 per prescription), more than doubled its utilization. Imbruvica ($10,000 per prescription) also had a significant increase in utilization. Read more about Ibrance here. In January 2017, Imbruvica received an expanded FDA approval to treat patients with marginal zone lymphoma, which will drive usage even higher. OptumRx 2016 Trend Insights 5

7 SPECIALTY TREND HIV summary +102% trend Fast growth for Cystic Fibrosis 20.2% total specialty trend The HIV class saw the 4th highest spend, 12.8%, and the 4th highest PMPM increase. This was caused by increased use of newer combination therapy medications, which are more expensive than older products. This is not necessarily a bad thing. Best-practice HIV therapy relies on multiple antivirals to slow the virus progression. So drug manufacturers now combine two, three, and even four agents in one tablet or capsule. The combined drugs are more effective and patients tend to be more adherent when there are fewer pills to take. Most HIV patients take three or more antiviral medications. 42% of OptumRx members take one unit versions: 1/3 of those contain four drugs, and 2/3 contain three drugs. While not the biggest category in dollar terms, cystic fibrosis had the 2nd highest trend over this period: 102.1%. This also led to the 5th highest PMPM increase. This stems from Orkambi, a breakthrough treatment for the underlying cause of cystic fibrosis (not just symptoms). Priced at $16-18,000/ prescription, a 300% increase in utilization over the reporting period yields tremendous growth. Read more about Orkambi here. Hepatitis C summary 32.4% total specialty trend The most notable change in this class is the slowing number of people being treated. Nationwide, HCV treatments have gone from 20-30,000 per year in earlier periods, up to 170,000 patients in That peaked at nearly 250,000 patients in 2015, but already the number of new patients was beginning to fall as the year progressed. 2 That decrease has continued, as we continue to reduce the initial group of patients with the highest need. 2 For this reporting period, fewer patients generated 1/3 fewer claims. Harvoni use dropped 42%, from over 10,000 claims to about 5,700. Sovaldi and Olysio saw a notable decrease as well. In all, HCV has dropped from 3rd to 5th in specialty class spending. It has also gone from being the 2nd highest contributor to class trend to actually reducing trend. OptumRx 2016 Trend Insights 6

8 TRADITIONAL TREND Traditional trend Traditional medications played a much smaller role in spending growth, accounting for just 12% of overall gross trend. Nevertheless, traditional medications still make up most of the pharmacy dollar over 65%. Looking at the three typical drivers, utilization was nearly flat (0.8%) while inflation and drug mix essentially cancelled each other out: 0.9% TRADITIONAL TREND Utilization was nearly flat, while inflation and drug mix cancelled each other out. 42% inflation Led by large price increases for insulin, and anaphylaxis therapy (i.e. Epi-Pen ). These were supplemented by more moderate increases for several classes, including erectile dysfunction agents and inhaled asthma combinations, plus several types of diabetes drugs (the biguanides, some non-insulin injectables, and DPP-4 inhibitors). 1.7% drug mix Helped mitigate the increases by substituting less costly drugs, mainly generics. Some generics, such as atypical antipsychotics and antidepressants, saw significant price improvements. In addition, we continued our vigilance over the use of compounded drugs, which can be quite costly. (The average cost for a compound prescription in 2015 was over $1,000). We noticed that the majority of the inflationary increases occurred in the earlier months of the comparison period. Since then we have actually seen slowing inflation, a trend we expect to continue. OptumRx 2016 Trend Insights 7

9 TRADITIONAL TREND Trend increase drivers The trend for injectable diabetic medications, SGLT-2 inhibitors, ADHD and narcolepsy medications was driven by both increased utilization and inflation. Insulin continues to have dramatic AWP increases, but also slight utilization increases. Oral anticoagulant trend was driven by increased utilization of more costly options (e.g. Eliquis and Xarelto ). On a more favorable note, ADHD saw a 2% increase in generic utilization, which helped to slightly mitigate its trend. Class Insulin Injectable Diabetic SGLT-2 Inhibitors and Combos Oral Anticoagulants ADHD and Narcolepsy Trend 9.1% 40.1% 44.3% 33.4% 5.8% Trend decrease drivers Atypical antipsycotics and NSAIDs saw reduced cost and drug mix due to generics for Abilify and Celebrex, respectively. Opioids had both decreased utilization and drug mix, while statins were driven by the new release of generic Crestor. Class Compounds Atypical Antipsycotics Statins NSAIDs Opioids Trend 95.2% 19.2% 10.7% 22.1% 9.8% OptumRx 2016 Trend Insights 8

10 TRADITIONAL TREND Top traditional classes by expenditures Class 2015 % 2016 % Trend Insulin 8.2% 8.9% 9.1% ADHD and Narcolepsy Medications 5.6% 5.9% 5.8% Statins and Combos 4.5% 4.0% 10.7% Antidepressants 4.0% 3.9% 2.0% Inhaled Asthma/COPD Combo 2.9% 3.2% 10.9% The top 10 traditional classes account for approx. 40% of expenditures Anticonvulsants 2nd Generation 2.9% 3.1% 8.5% Opioid Agonists and Combos 3.2% 2.8% 9.8% Contraceptives 2.7% 2.8% 4.3% The affect on traditional expenditures The top 10 traditional classes affect traditional expenditures in different ways: Diabetes: Insulin and SGLT inhibitors increased utilization and inflation ADHD and Narcolepsy: Increased utilization and inflation offset by higher generic use Statins: Increased generic use with Crestor going off-patent Antidepressants: Improved pricing for generics (especially Cymbalta ) Asthma/COPD: Major drugs are brands, so expect AWP inflation. Most significant is Advair Anticonvulsants: AWP inflation for Lyrica, but also increased utilization Opioids: Increased use of generics (OxyContin ) as well as decreased use of Subsys ($12-16,000/ Rx) Contraceptives: Inflation, increased utilization, offset by improved drug mix DPP-4: Januvia /Janumet patent expiration, but also high inflation Atypical Antipsychotics: Price improvement for generic Abilify (31% decrease) OptumRx 2016 Trend Insights 9

11 CROSS CLASS UTILIZATION Top impact drugs Traditional and specialty drugs with trend increases/decreases: Drug Name Percent PMPM Change Contribution to Trend Orkambi 292.8% 5.6% Trend causes Triumeq Humira Pen 153.8% 43.6% 5.4% 29.1% Increase: Novel agent (i.e. Orkambi) Greater MD acceptance (i.e. Triumeq) Decrease: Patent expired (i.e. Abilify, Glumetza, Crestor) Reduced utilization (i.e. Harvoni) High inflation and utilization (i.e. Humira pen) New indication; increased dosage (i.e. Stelara) Truvada Stelara Abilify Glumetza Harvoni Crestor -84.7% -67.9% -43.4% -24.8% Decrease 37.8% 27.9% Increase 5.6% 5.1% -14.0% -5.8% -32.4% This chart shows some of the biggest movers by percentage of trend increase or decrease. There is no common theme or cause that unites all of them. For example, the HCV drug, Harvoni experienced slowing utilization due to the general fall-off in HCV treatments. -8.8% Meanwhile, Orkambi saw explosive growth as a novel agent that for the first time can treat the underlying protein deficiency in cystic fibrosis (see page 9). An existing drug, Stelara, received a new indication for Crohn s disease in 2016, which helped drive new sales. OptumRx 2016 Trend Insights 10

12 CROSS CLASS UTILIZATION Many treatments require traditional and specialty drugs Oftentimes we look at pharmacy spend in distinct groupings, separately isolating the evaluation of specialty and traditional medications. However, members are obtaining treatments for specific conditions from both specialty and traditional medications. Cancer treatment has the greatest reach across specialty and traditional, with traditional medications accounting for 88% of the claims, and specialty medications accounting for 91% of the cost. Oncology reaches across traditional and specialty Traditional and specialty drug use by class* Cost Claims Traditional Specialty Traditional Specialty 88% claims 91% costs Oncology Asthma/COPD Antibiotics 9% 96% 94% 91% 4% 6% 88% >99% >99% 12% <1% <1% Seizure 96% 4% >99% <1% Cholesterol 98% 2% >99% <1% 88% of all oncology claims are traditional 91% of all oncology costs are specialty *Percentages rounded for clarity. Rows may not equal 100%. OptumRx 2016 Trend Insights 11

13 TREND MANAGEMENT OptumRx trend management The OptumRx approach to managing trend is to focus on connecting total condition spend and pharmacy s impact across benefits. We make the connections between clinical efficiency, cost savings and consumer choice that help payers manage the total cost of the condition across benefits and help consumers more easily navigate the system. Clinical efficiency Cost savings Consumer choice OptumRx strategies and savings Premium Formulary 1-3% decrease in Rx spend Retrospective Drug Utilization Review (Safety Management) $138 Rx savings Utilization Management % decrease in Rx spend (Gaps in Care) $547 medical savings Specialty Management 9-14% decrease in specialty Rx spend Vigilant Drug List ~0.5% decrease in net PMPM spend Compound Management Strategy 90% reduction in compound expenditures OptumRx 2016 Trend Insights 12

14 TREND MANAGEMENT Pharmacy care services: The next generation $11-16 PMPM savings on medical costs, incremental to pharmacy savings 3 The pharmacy model has to change. OptumRx is taking concrete action to evolve pharmacy services to emphasize value over just price and volume. We re aligning with physicians, including our own growing health network, to deliver better and more efficient care. We re shifting the scorecard from drug pricing to net promoter score, satisfaction, medical costs and care outcomes. That s a new agenda that will serve everyone s interests. Old Approach OptumRx: Value over volume Channel flexibility 12% increase in adherence on average for targeted populations 4 Mail-driven model Retail-driven model Empowering physicians Tailored offerings Aligned with client goals to lower total health care costs Site of care strategies Synchronized engagement 60% enrollment in condition management programs through pharmacy 5 Aligning with client interests to drive value We re taking a big-picture, lowest net cost approach that adds value to the health system and aligns with client goals: Channel flexibility means promoting member choice and convenience over PBM profit. Synchronized engagement turns Rx member calls health care s most frequent touchpoint into opportunities to engage individuals with health and savings options. Determining the site of care best suited to optimal health and financial results. Partnering with clients to tailor customized benefit plan solutions that drive best outcomes. We empower physicians with real-time, patient-specific information through Electronic Medical Records to avoid incomplete data and missed clinical opportunities. OptumRx 2016 Trend Insights 13

15 References 1. Segal Consulting Segal Health Plan Cost Trend Survey. PDF. 2. IMS Institute. Medicines Use and Spending in the U.S. April PDF. 3. Optum Study of 80+ Clients, OptumRx Book of Business, OptumRx Client Data, January-October About OptumRx OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. Our high-quality, integrated services deliver optimal member outcomes, superior savings and outstanding customer service. We are an Optum company a leading provider of integrated health services. To learn more about OptumRx and to discuss potential pharmacy benefit savings, please us at optumrxsales@optum.com or visit optum.com/optumrx Main Street, Irvine, CA optumrxsales@optum.com optum.com/optumrx All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners Optum, Inc. All rights reserved.