Friday
Apr062018

The PBM side of CVS

The PBM side of CVS
 

By Clive Riddle, April 6, 2018

 

Assuming the CVS acquisition of Aetna clears all final hurdles, perhaps the most attention given to the merged company is in respect to the retail synergies. But the CVS Caremark PBM also deserves considerable attention. After all, Cigna’s big merger recently announced with Express Scripts was purely a PBM play.

 

With that in mind, its interesting to poke through the just released 14-page CVS Health Drug Trend Report 2017. Similar to Express Scripts previously released 2017 report, the CVS Health report was certainly positive, and they touted that drug prices for clients  rose “at a minimal 0.2 percent, despite manufacturer price inflation near 10 percent.”

 

But it must be noted that the touted 0.2 percent increase was just for prices. There was 1.7% cost growth due to utilization, yielding a total pmpy drug trend in 2017 of 1.9%, still quite a positive trend.

 

Here is additional data CVS shared about their client experience in 2017:

·         While CVS drug price growth was 0.2%, the manufacturer AWP inflation rates were 9.2& for traditional brands, 8.3% for specialty brands, and 0.4% for generics.

·         The CVS generic dispensing rate was 86.1%.

·         CVS traditional and specialty brands accounted for 14% of prescriptions dispensed, but 69% of pharmaceutical spend.

·         The CVS specialty trend consisted of 3.7% price growth plus 9.2% utilization cost growth for a total 12.9% 2017 specialty trend.

·         CVS gross client costs pmpm were 108.42 pmpm in 2017 compared to $104.10 in 2016.

·         For CVS Clients with managed formularies, costs were $88.94 pmpm compared to $87.43 pmpm in 2016.

·         The managed formulary differential in overall drug trend for 2017 resulted in a 1.7% trend with managed formulary clients compared to 4.2% trend for other clients.

·         42 percent of CVS Health commercial PBM clients spent less on their pharmacy benefit plan in 2017 than they had in 2016.

·         For clients aligned with the company's managed formularies, drug price declined by 0.1 percent, in 2017, as compared to the overall 0.2 percent drug price growth.

·         Member out of pocket costs pmpm declined from $11.99 in 2016 to $11.89 in 2017.

·         In 2017 24% of members had zero out of pocket costs (no claims), 49.4% of members had out of pocket costs under $100, 14.6% had out of pocket costs between $100-$299, 5% had out of pocket costs between $300 - $499, 4.3% between $500-$599 and 2.7% above $1,000.

 
Friday
Mar302018

Wal-Mart and Humana: How Healthcare on Wall Street Imitates Hollywood

Wal-Mart and Humana: How Healthcare on Wall Street Imitates Hollywood
 

 

By Clive Riddle, March 30, 2018

Hollywood notoriously chases a hot movie trend with much more of the same – imitation being the most sincere form of flattery.  Wall Street when it comes to healthcare continues to flatter Hollywood by imitating this strategy as best they can.

 

In the 1980s, public hospital companies rushed to acquire health plans. They subsequently rushed to spin-off or otherwise unload them. That’s how Humana become just a health plan company. In the 1990’s, the PPM industry was born as integrated delivery systems where split up, giving birth to PhyCor an others who subsequently flamed out.

 

More recently, on the heels of ACA implementation, the mantra was to increase clout to succeed in the Marketplaces and expanding Medicaid and Medicare Advantage programs. Aetna announced the Humana acquisition and Centene announced the HealthNet acquisition within a day of each other in early July 2015. Three weeks later Anthem announced the Cigna acquisition.

 

Then in February 2017, Aetna-Humana and Anthem-Cigna separately announced on the same day the death of their proposed mergers, thanks to DOJ opposition, and in Anthem-Cigna’s case, merger indigestion. Additionally, the new Trump administration and Republication Congress’ zeal for Repeal made the merger’s marketplace strategy seem moot.

 

But a year later a new blockbuster movie formula has developed. There is Amazon style retail market disruption looming over the pharmacy sector in particular but the rest of healthcare as well, and the specter of the mysterious Amazon-BershireHathaway-JPMorgan healthcare venture. There is the outcry over pharmaceutical costs, and the questioning of the PBM sector’s role.  From this backdrop the CVS-Aetna merger emerges in early December.  Then early this month Cigna announces their Express Scripts acquisition.

 

And now the Wall Street Journal and many others report Walmart is in early stage acquisition talks with Humana. WSJ notes the annual revenue of WalMart is $500 billion and Humana’s is $54B, compared to $185B fir CVS, $61B for Aetna, $42B for Cigna and $100B for Express Scripts.

 

Will the Walmart-Human movie deal get inked? Will any of these new projects make it through production and get released? And what sequels and similar projects are under development?

 
Friday
Mar302018

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition
 

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

 

CDC director pledges to bring opioid epidemic 'to its knees'

The new director of the top U.S. public health agency on Thursday pledged to work to bring the nation's opioid epidemic "to its knees" and said he believes the AIDS epidemic could be ended in three to seven years.

ABC News

Thursday, March 29, 2018

Walmart talking with Humana on closer ties; acquisition possible: sources

U.S. retailer Walmart Inc (WMT.N) is in early-stage talks with health insurer Humana Inc (HUM.N) about developing closer ties, with the acquisition of Humana being discussed as one possibility, people familiar with the matter said on Thursday.

Reuters

Thursday, March 29, 2018

White House: 'No one is talking about privatizing the VA'

President Donald Trump said Thursday he fired Veterans Affairs Secretary David Shulkin because he wanted to give veterans more choices, but a spokesperson said his actions did not signal a desire to privatize veterans' health services.

Politico

Thursday, March 29, 2018

Thousands Mistakenly Enrolled During California’s Medicaid Expansion, Feds Find

California signed up an estimated 450,000 people under Medicaid expansion who may not have been eligible for coverage, according to a report by the U.S. Health and Human Services’ chief watchdog.

Kaiser Health News

Wednesday, March 28, 2018

Urgent Care Center Utilization Skyrocketed by 1725% in Last Decade

Healthcare payers saw urgent care center utilization grow by 1725 percent from 2007 to 2016, indicating that urgent care may the one of the fastest-growing choices for receiving healthcare.

HealthPayer Intelligence

Monday, March 26, 2018

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.
 
Friday
Mar232018

Animal Farm Meets Health Care

Animal Farm Meets Health Care
 

By Kim Bellard, March 23, 2018

 

 

In George Orwell's classic Animal Farm, the animals revolt against their human masters, and establish a classless society with the inspiring principle, "All animals are equal."  As events play out, their society devolves into a dictatorship with a ruling elite, and the principle becomes "All animals are equal, but some are more equal than others."

This, surprisingly, makes me think of health care.  

 

I am old enough to remember when maternity coverage was at best only very limited even in employer group health plans.  It took the Pregnancy Discrimination Act (1978) to require them to treat maternity the same as any "illness," and, even then, individuals plans often did not include it until ACA required it Similarly, coverage for mental health was typically skimpy until the Mental Health Parity Act (2008) required parity.

Preventive services were usually only available for (the small percentage of) people enrolled in HMOs, until network-based managed care plans grew more widespread in the 1990's.  The same happened with prescription drug coverage, which used to only be available to the minority of people with "major medical" coverage.

It took the Affordable Care Act to standardize what "essential benefits" should be included in health plans.
For services like dental, vision, or hearing, not so much.   Evidently, some services are more equal than others.

We've managed to push our rate of people without health insurance to 
around 11%, but it's more than double that for dental insurance, and worse yet for vision coverage.  For seniors, the figures are significantly worse

The real question should be, why do we have separate coverages for services like dental or vision, especially when many lack them?

This matters.  
According to NCHS, 14% of Americas report hearing trouble, 9% vision trouble -- and 7% have no natural teeth left (25% for those over 75).  There is a well documented link between oral health and our overall health, yet a study found that dental care had the highest financial barriers to care, compared to other health services.

 

If you break a bone, you'll see a doctor; if you break a tooth, you'll see a dentist.  If you have problems with your throat, you'll see a doctor; if you have problems with your gums, you'll see a dentist.  If you want to correct your vision with glasses, you'll see a optometrist; if you want to correct it with Lasik, you'll see a physician.

 

Specialization is understandable, as most physicians end up doing, but I have to wonder why some types of specialization start at the beginning of training, rather than after the basic medical training (see my previous article on balkanized medical education).

We accept all this because, well, that's the way it always has been.  That doesn't mean it makes sense, or that it is best for our health.

We each only have one body.  Although some health issues are fairly specific, we are increasingly realizing that many are systems issues involving multiple parts of the body.  It's time to stop drawing artificial distinctions between what care we get, who gives it to us, and how those professionals get trained. 

Health is not equal to health care.  Health care should not be limited to medical care.  We need to get past "historical accidents" and focus on what is best for our health, and our care.

Unless you actually do believe that all health services, and all health care professionals, are equal, but some are more equal than others.

 

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

 
Friday
Mar232018

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition
 

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

 

CMS plans Medicaid 'red-tape' rollback for states

States could see less administrative burdens in the near future thanks to a proposed regulatory rollback by the Medicaid agency.

Fierce Healthcare

Friday, March 23, 2018

Graphic: Opioid Painkiller Is Top Prescription In 11 States

Americans fill about 4.5 billion prescriptions each year, at a cost of more than $323 billion. But what are we actually buying?

Kaiser Health News

Thursday, March 22, 2018

Medical Research, Drug Treatment And Mental Health Are Winners In New Budget Bill

The big budget deal reached this week in the House doesn't include a long-sought-after provision to stabilize the Affordable Care Act marketplaces. But the $1.3 billion plan, set to fund the government through September, has lots of new money for medical research, addiction treatment and mental health care.

NPR

Thursday, March 22, 2018

States Extend Medicaid For Birth Control, Cutting Costs — And Future Enrollment

The Trump administration is weighing whether to allow Texas to receive millions of federal Medicaid dollars for its family planning program, which bars abortion providers.

Kaiser Health News

Thursday, March 22, 2018

 

Highmark Health added $1B in net income in 2017 with a ‘substantial turnaround’ in ACA plans

Highmark Health’s Affordable Care Act exchange plans were profitable for the first time in 2017 as the insurer added $1 billion in net income compared to 2016. The Pittsburgh-based Blues plan that covers nearly 5 million members in Pennsylvania, West Virginia and Delaware saw significant growth in commercial and government plans, including its Medicare Advantage segment.

Fierce Healthcare

Tuesday, March 20, 2018

 

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

 

 
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