Specialty Medical Benefit Management of IG: Issues for
Consideration Lauren Barnes Senior Vice President Avalere Health,
LLC
Slide 2
Under Medicare, the Benefit Category Determines Coverage,
Coding and Payment Pump Coverage, Coding, and Payment HyQ Drug
Coverage, Coding, and Payment HyQ Administration Coverage, Coding,
and Payment DME Incident toDMEIncident to DME E Code DME fee
schedule N/A J Code 95% AWP N/A N/A (patient self- administers)
Home Health + DME E Code DME fee schedule N/A J Code 95% AWP N/A
Home Health PPS 3 Physician Office E Code DME fee schedule Supply
(no payment) J Code 95% AWP J Code ASP+6% 1 CPT Code MPFS HOPD* E
Code DME fee schedule Supply (no payment) J Code 95% AWP C/J Code
ASP+X% 2 CPT Code/APC OPPS 1 Reimbursement will be at WAC+6% until
ASP is available. 2 Reimbursement will be at 95% of AWP until WAC
is available and then will be WAC+6% until ASP is available. When
eligible for pass- through payment, reimbursement will be ASP+6%;
after pass-through status expires, reimbursement will be ASP+5%
(CY2011). 3 Patient must meet eligibility criteria for home health
services (patient must be deemed home bound). AWP = Average
Wholesale Price MPFS = Medicare Physician Fee Schedule OPPS =
Outpatient Prospective Payment System APC = Ambulatory Payment
Classification PPS = Prospective Payment System HOPD = Hospital
Outpatient Department CPT = Current Procedural Terminology ASP =
Average Sales Price *See Appendix slides 60-61 Medicare coverage
and payment varies significantly by setting of care
Slide 3
Private Payer Coverage, Coding and Payment for IG Varies By
Setting of Care Immune Globulin Coverage and Coding IG
Administration Coverage and Coding DME Drug: J-code External
Infusion Pump: E/S Code Home health or home infusion benefit 1
Coding & payment vary Home Health +DME Drug: J-code External
Infusion Pump: E/S Code Home health or home infusion benefit 1
Coding and payment vary Physician Office Drug: J-code External
Infusion Pump: E/S Code CPT Code Fee Schedule HOPD Drug: J-code
External Infusion Pump: E/S Code Coding and payment vary Private
payers may use different reimbursement benchmarks for drug payments
(e.g. average sales price (ASP), wholesale acquisition cost [WAC]),
and Average Wholesale Price [AWP]) CPT = Current Procedural
Terminology 1 Patient must meet private payer eligibility criteria
for home health/home infusion benefit; these criteria are generally
much less stringent than Medicares criteria. In all settings of
care, other than the hospital inpatient setting, Immune Globulin is
paid for separate from the administration
Slide 4
Private Payers Are Likely to Focus on Management of Specialty
Drug Spending, Including IG Source: ESI Drug Trend Report, 2011
Specialty drugs, such as IG, are the fastest-growing segment of
drug spend. This is likely to lead to an increased focus on
utilization management (UM) techniques for expanded indications
Drug Spending Trend, 2006-2011
Slide 5
Most Private Plans Manage IG Through the Medical Benefit Using
a Specialty Pharmacy In addition, 80 percent of payers managed IG
through specialty pharmacy in 2011 Source: EMD Sereno Specialty
Digest, 2011
Slide 6
Private Payers Are Likely to Increase Their Focus on Management
of IG Pressures to Control Costs Due to the changing landscape,
health plans are likely to increase their focus on management of
specialty medical benefit drugs through increased UM Increase in
Specialty Products The prevalence of specialty products is
increasing in the market and these products account for a large
portion of total drug spend making them a target for health plans
Potential for Increased Focus on Management of IG through Specialty
Pharmacy 40 percent of private payers indicated that within the
next year they intended to limit the number of subcutaneous IG
agents on formulary based on favorable pricing or rebates from
manufacturers * Source: *EMD Sereno Specialty Digest, 2011
Slide 7
Private Payer Perspective Private Payers may demand increased
evidence to differentiate IG products To date, limited evidence has
differentiated IG products Absent evidence, payers may view
products as interchangeable and demand price concessions for
preferred positioning Increases pressure on medical versus pharmacy
benefit IG products Private Payers may have higher thresholds for
coverage of expanded indications for IG Private Payer Perspective
Private Payers may demand increased evidence to differentiate IG
products To date, limited evidence has differentiated IG products
Absent evidence, payers may view products as interchangeable and
demand price concessions for preferred positioning Increases
pressure on medical versus pharmacy benefit IG products Private
Payers may have higher thresholds for coverage of expanded
indications for IG Private Payer Tools Clinical policies (cover or
non- cover decisions) Utilization management i.e., Step edits
Guidelines and care pathways Formulary evaluations
Pay-for-performance initiatives Value-based insurance designs
Private Payer Tools Clinical policies (cover or non- cover
decisions) Utilization management i.e., Step edits Guidelines and
care pathways Formulary evaluations Pay-for-performance initiatives
Value-based insurance designs Private Payers Increase Thresholds
for IVIG Coverage and Payment Payers are likely to demand increased
evidence to differentiate IG Products and when considering expanded
indications
Slide 8
Panel Discussion
Slide 9
Specialty Medical Benefit Management: Immunoglobulin Michael
Baldzicki, CRCM Vice President AxelaCare Health Solutions A
National Home Infusion Provider
Slide 10
Payer & Specialty Medical Benefit
Slide 11
Payer Insight Areas: Specialty Pharmacy Average wholesale price
(AWP) Average sales price (ASP) Average manufacturer price (AMP)
Wholesale acquisition cost (WAC) Average wholesale price (AWP)
Average sales price (ASP) Average manufacturer price (AMP)
Wholesale acquisition cost (WAC) Home health Physician office
Hospital (inpatient and outpatient) Ancillary Home health Physician
office Hospital (inpatient and outpatient) Ancillary Copayments
Coinsurance Out-of-pocket (OOP) max/min Deductibles Doughnut hole
Copayments Coinsurance Out-of-pocket (OOP) max/min Deductibles
Doughnut hole Data Reimbursement Site of Care Benefit Design
Pharmacy claims system Medical claims system Specialty fulfillment
system Pharmacy claims system Medical claims system Specialty
fulfillment system
Slide 12
Site of Care: Shift of Reimbursement Hospital Outpatient
Hospital Inpatient MD Office Buy & Bill Home Infusion Site of
Care Options: Payers MD Office Specialty Medical Benefit MD Office
Specialty Pharmacy Benefit Expensive Cost-effective for Member
Decrease Total Cost of Care Pharmacy Benefit
Slide 13
MBaldzicki Product Demand & Clinical Needs Percentage of
Usage Volume Patients Growth Per Year Primary
Immunodeficiencies36.0%2.1% Neurology25.1%9.9% Hematology /
Oncology25.7%3.8% Cardiology1.5%5.6% Rheumatology /
Nephrology5.4%11.5% All Others*6.3%13.4% TOTAL100.0%8.2% IVIG &
Subcutaneous Immune Globulin - United States United States IVIG
Forecast, 2009 2015
Slide 14
A New, Proprietary Home Infusion Tool 14 A new, proprietary
iPAD home infusion tool, tool functions as an outcomes reporting
and medical management resource for referring physicians and
payers.
Slide 15
Home Infusion Therapy Monitoring Physical Assessments
Disability / Activities of Daily Living (ADL) Quality of Life (QOL)
Validated Outcomes Measures IVIg Patient Data Collection
CIDP/GBS/Peripheral Neuropathy Myasthenia Gravis Primary
Immunodeficiency Outcomes vs. Dose Over Time Careators Care Support
Physician Data Review Administrators Coordinators Researchers Dose,
Side Effect, Clinical Monitoring Pharmacist Data Review
Slide 16
Case Study 1 New Neurology Patient Response to Therapy
Peripheral neuropathy patient, new to IVIG, receives recommended
dosing of 2gm/kg followed by 1gm/kg every three weeks. Physical
ability as measured by grip strength increases over 20% after only
three doses (less than two months) Outcomes tool shows physician
that patient has responded to therapy, confirming diagnosis, and
dramatic patient benefit. A non-responsive patient would be
identified in this timeframe (2 mo.), and could come off of drug,
saving payer as much as 60% to IVIG drug cost, as compared to
typical 6 mo. office visit decision. This would be approximately
$50k in savings for a non- responder, and faster change to a more
effective therapy option. 16 Case Study Example: Immune Therapy
Monitoring
Slide 17
Alzheimer's Indication IVIG Alzheimers Indication
Slide 18
Alzheimers Prediction
Slide 19
GLOBAL DEMAND FOR IVIG/SCIG WITH/WITHOUT ALZHEIMERS DISEASE -
2008 - 2018 (Metric Tons)
Slide 20
US source plasma collection forecast, 1996 -2013
Slide 21
Currently, IVIG is not FDA approved for the treatment of
Alzheimer's disease, but physicians are free to prescribe it if
they believe it is warranted in a particular case. Manufacturers
are confident it will be approved in the next few years. Some
analysts estimate that as many as 2,000 Alzheimer's patients in the
US have received IVIG treatment. IVIG & Alzheimers
Slide 22
Questions
Slide 23
References International Blood & Plasma News The Marketing
Research Bureau, Inc. PPTA (Plasma Protein Therapeutics
Association) NDDR=National Donor Deferral Registry FFF - Plasma New
Products and Development Dermatology, Infectious diseases,
Ophthalmology, Obstetrics/Gynecology, others IVIG 2015: A Forecast
of the Polyvalent Intravenous Immune Globulin (IVIG) Market in the
United States in 2015. Orange, CT *AMR Patient Profile "Intravenous
Immune Globulin Hospital Patient Profile Reports" - United States
Edition 2009 Axelacare Health Solutions Internal Data Analytics
& Outcomes Annual Reports of major pharmaceutical companies:
Baxter, CSL, Grifols, Octapharma, Telecris U.S. Census Bureaus
released data
Slide 24
Specialty Medical Benefit Management: Immunoglobulin Site of
Service Implications on IVIG Cost to Treat Michael T. Einodshofer,
RPh, MBA Director of Utilization Management, Walgreens Specialty
Pharmacy Division [email protected] 2013 Walgreen
Co. All rights reserved.
Slide 25
Site selection for infusion is largely dictated by the
prescribing physician Each place of service may have different fee
schedules for medications Each place of service may have different
benefit implications and limitations Remicade, IVIG, Tysabri are
the most prevalent non-chemo drugs in medical. Site of Care
Optimization distribution of drugs covered in the medical benefit
generally reside in 3 main sites of service 2013 Walgreen Co. All
rights reserved. Typical drug related medical benefit costs by site
of care* Outpatient Hospital Physician Office All Others Home
Infusion / Infusion Suite *Allowable amounts based on Walgreens
internal analysis, will vary by client ~10% ~5% ~45% ~40%
Slide 26
Site of Care Optimization to manage medical pharmacy costs 2013
Walgreen Co. All rights reserved. Lower cost, lower risk, more
convenient ATS options Specialty Infusion Site of Care Optimization
Move clinically appropriate patients from high cost of care
delivery settings to lower cost of care alternate treatment sites
(aka ATS) Physician Office Home Infusion Infusion Suites
Slide 27
Site of Care Optimization 2013 Walgreen Co. All rights
reserved. Walgreens client date on file. Dates of service 1/1/2011
12/31/2011 1.9 million commercial lives. IVIG defined as J1459,
J1557, J1561, J1566,J1567, J1568,J1569, J1572, J1599. Claims
meeting specified exclusion rules are not included herein. Each dot
represents the cost per 500mg per immune globulin claim.
Significant pricing variability is observed within hospital
outpatient site of service. Site of Care Optimization lowers the
average price per unit and provides more price consistency.
Slide 28
Much lower variance and lower average cost per unit at MD
office and Home Infusion / Infusion Suite 2013 Walgreen Co. All
rights reserved. Walgreens client date on file. Dates of service
1/1/2011 12/31/2011 1.9 million commercial lives. IVIG defined as
J1459, J1557, J1561, J1566,J1567, J1568,J1569, J1572, J1599. Claims
meeting specified exclusion rules are not included herein.
Slide 29
While home infusion offers the lowest cost per unit, majority
of patients are treated in the most costly place of service 2013
Walgreen Co. All rights reserved. Walgreens client date on file.
Dates of service 1/1/2011 12/31/2011 1.9 million commercial lives.
IVIG defined as J1459, J1557, J1561, J1566,J1567, J1568,J1569,
J1572, J1599. Claims meeting specified exclusion rules are not
included herein.
Slide 30
Questions? 2013 Walgreen Co. All rights reserved.
Slide 31
Specialty Medical Benefit Management: Immunoglobulin Ann
Nguyen, PharmD Staff Vice President
Slide 32
Immunoglobulins Challenges IVIG Products Clinical mechanism of
IVIG/SQIG action remains undetermined Lack of disease specificity,
numerous FDA indications and many off label uses Outcomes Clinical
effectiveness and follow-up are often not documented Extended
treatment length without clinical outcomes observed Market Market
consolidation, fewer manufacturers controlling distribution channel
and allocation Consumer demand and consumption continuing to
grow
Slide 33
Immunoglobulins Mgmt Strategies MemberPhysician Ancillary HIT
& SPP Utilization Mgmt Care Mgmt Benefit alignment: Rx &
Med In-Network incentives In office infusion incentives Limit IVIG
distribution channel to a select few Preferred HITs / SPPs
w/demonstrable outcomes Contract pricing Appropriate use w/clinical
outcomes & length of therapy criteria Preferred product
selections Pre-cert required (med) Case Mgmt & Coordination
Robust meaningful analytics
Slide 34
Specialty Medical Benefit Management: Immunoglobulin Alignment
of the Patient, Provider, Plan and SOC Continuum Bruce Phelan
Compass BioPharma, LLC Compass BioPharma, LLC- All Rights
Reserved
Slide 35
Chronic Care Management 40% + of the US population has one or
more chronic condition 1 50% of working age Americans have at least
one chronic condition 2 The prevalence of chronic disease is
increasing in the elderly and non-elderly populations 3,4 A
significant number of people have multiple chronic diseases Chronic
conditions account for 75% of health spending in the US 5 By 2017,
insurers will be spending an average of 32% more for their
individual members' medical claims 6 Adapted from Health ReformGPS,
L. Cartwright-Smith, 2011 [1] Chronic diseases are conditions that
last a year or more and require ongoing medical attention and/or
limit activities of daily living.W. Hwang, et al., Out of Pocket
Medical Spending for Care for Chronic Conditions. Health Affairs.
20:2689 (2001). [2] C. Hoffman and K. Schwartz. Eroding Access
Among Nonelderly U.S. Adults with Ch ronic Conditions: Ten Years of
Change.Health Affairs. 27:w340 w348 (2008). [3] K. A. Paez, L.
Zhao, W. Hwang. Rising Out Of Pocket Spending for Chronic
Conditions: A Ten Year Trend. Health Affaris. 28:1525 (2009). [4]
K. E. Thorpe, Lydia L. Ogden, K. Galactionova. Chronic Conditions
Account for Rise in Medicare Compass BioPharma, LLC- All Rights
Reserved [5] H.Tecco, Rock Health, HIT Consultant, February2013
Cost of the Future Newly Insured under the Affordable Care Act
(ACA), Society of Actuaries, March 2013
Slide 36
Immunoglobulin Dynamics Primary Immunodeficiency (PI) 300K
patient population 10% ~ 28,000-30,000 patients receive Ig therapy
Neurologists have demonstrated a growing acceptance of IVIg for
patients with Neurological conditions Safety, Efficacy, Supply, and
Outcomes (CIDP, MNN, MG, GB, and AD) Ig Manufacturers' have
leveraged significant investments to ensure: Expanded donation,
efficient Ig fractionation, and adequate Ig supply Disease state
awareness and education Distribution and service models to provide
access to care Compass BioPharma, LLC- All Rights Reserved
Slide 37
Ig Ambulatory Variables Compass BioPharma, LLC- All rights
reserved Specialty Infusion/Pharmacy Reimbursement Compression Cost
of Goods (acquisition / procurement) Competition M&A
Consolidation MCO AWP to ASP Methodology Labor Costs
(Fixed/Variable Clinical/Ops/Corporate) Infrastructure (IT,
Logistics, DMPs) Appropriate Patient Cost Containment HC Reform?
Opportunity To Adapt
Slide 38
Moving from Volume to Value Compass BioPharma, LLC- All Rights
Reserved IVIg PI Patien t IVIg PI Patien t Medical Benefit Hospital
Homecare Med Benefit IVIg Pharmacy Med Benefit SCIg Pharmacy
Benefit SCIg (1-2X) Pharmacy Medical and Pharmacy Benefit Designs
that encourage benefit and SOC migration Med Benefit IVIg Med
Benefit IVIg Med Benefit IVIg AIS Phys Office Amb Clinic AIS Phys
Office Amb Clinic AIS Phys Office Amb Clinic SOC significantly
influences Ig Total Cost of Care under the medical benefit 60-65%
of all IVIg grams still administered in a hospital setting 60-65%
of all IVIg grams still administered in a hospital setting 1 1 3 3
2 2 4 4 5 5
Slide 39
Ig Efficiency Considerations Although only 7 FDA approved
indications, 100+ ICD-9 codes support Ig through proven clinical
data and historical acceptance Leads to inefficient/experimental Ig
dosing patterns Opportunity for Clinical / Medical treatment
algorithms (IVIg /SCIg) Medical Benefit data barriers exist to
track, monitor, and manage IT / data management enhancement-
integrated EMR/EHR transference Medical Benefit Data Stratification
(Hospital, OPIC, HIT, AIS, Phys Office) Compass BioPharma, LLC- All
Rights Reserved New models of care represent an effort to solve
deeply embedded Healthcare delivery problems experienced by
organizations of all sizes and SOCs New models of care represent an
effort to solve deeply embedded Healthcare delivery problems
experienced by organizations of all sizes and SOCs GE Health, 2011,
01-Elhauge-Chap-01.indd, Oxford Press, 2010