Mercer Short Duration Fixed Income Fund Class Y-3 · NASDAQ:MSDYX
Mercer Short Duration Fixed Income Fund Class Y-3 — Mercer — EMPAA 2022
67 slides from Mercer Short Duration Fixed Income Fund Class Y-3's conference presentation, Nov 14, 2022
Slide 1: Medicaid Pharmacy Cost Savings: Taking Policy Ideas to the Next Level
welcome to brighter Medicaid Pharmacy Cost Savings: Taking Policy Ideas to the Next Level November 14, 2022 Sara Drake RPh, MPH, MBA, Principal, Minneapolis A business of Marsh McLennan
Slide 2: Our discussion today on Medicaid Cost Savings
Our discussion today on Medicaid Cost Savings 1 Pharmacy Program Redesign 2 Drug Product Selection and Manufacturer Contracting 3 Prescription Payment Rate 4 Utilization Improvement A Principal and pharmacist in Mercer’s Government Human Services Consulting practice, Sara assists state clients in ev
Slide 3: Statement of Disclosure
Statement of Disclosure Sara Drake has no relevant conflicts of interest to report 3
Slide 4: Learning Objectives
Learning Objectives At the conclusion of this educational activity participants will be able to: Describe the challenges that Identify at least three Recognize when state Medicaid Pharmacy innovative cost incentives are or are not Directors face related to containment policy aligned with a cost pres
Slide 5: Learning Assessment Questions
Learning Assessment Questions True or False? State Medicaid programs are unlikely to encounter stakeholder resistance to a change in policy such as 340B provider payment. True or False? If managed care capitation rates are increased due to brand over generic preference on a PDL, the MCO benefits if
Slide 6: Warm-up #1: What was the best concert you ever attended?
Warm-up #1: What was the best concert you ever attended? ⓘ Start presenting to display the poll results on this slide.
Slide 7: Who is this guy?
Who is this guy? And what can we learn from him? During his great set, the power went out Without hesitation, he says “That’s a bummer. I guess we’ll have to play acoustic now” What can learn from Tom? Sometimes the external environment creates obstacles that you don’t anticipate. But you can still
Slide 8: Warm-up #2: What was the WORST concert you ever attended?
Warm-up #2: What was the WORST concert you ever attended? ⓘ Start presenting to display the poll results on this slide.
Slide 9: Who is this guy?
Who is this guy? And what can we learn from him? Entire set was to spin a record, get the crowd to cheer, ask if they like the song, “do you want to take it to the next level” – rinse and repeat What can learn from Timbaland? Even if things seem to be going well, even if stakeholders seem to general
Slide 10: Pharmacy Program Redesign Options
Pharmacy Program Redesign Options • Pharmacy Service Delivery Design • PBM Contracting and Transparency • High Cost Drug Risk Mitigation
Slide 11: Pharmacy Service Delivery Design
Pharmacy Service Delivery Design + ‘+
Slide 12: How many states have fully carved pharmacy out of managed care?
How many states have fully carved pharmacy out of managed care to either FFS or a Single PBM? a) 4 b) 50 c) 8 d) 20
Slide 13: How many states have fully carved pharmacy out of managed care?
How many states have fully carved pharmacy out of managed care to either FFS or a Single PBM? a) 4 b) 50 c) 8 d) 20
Slide 14: Pharmacy Program Design Trends
Pharmacy Program Design Trends Full Pharmacy Carve-Out Full Pharmacy Carve-In Single PBM Pending Carve-out or Single PBM Partial Pharmacy Carve-out N/A – No Managed Care 14
Slide 15: Beyond Carve-In or Carve-Out
Beyond Carve-In or Carve-Out Next Level Pharmacy Program Designs State Mandated Pharmacy • MCOs required to pay pharmacy providers using the FFS methodology Reimbursement • State selects a single PBM and requires all MCOs to contract with that PBM Mandated Single PBM • The MCOs remain at risk for th
Slide 16: PBM Contracting and Transparency
PBM Contracting and Transparency
Slide 17: PBM Revenue Sources
PBM Revenue Sources How PBMs Make Money Retail Spread Mail/Specialty Rebates Rebate Admin Data/Other Misc. Fees Margin Fees AWP discounts and Rebates received Claims and other Postage, admin dispensing fees; PBM PBM pre-tax operating from drug 2%–4% admin fee utilization data is for fees, clinical p
Slide 18: Next Level PBM Transparency
Next Level PBM Transparency Moving Beyond Spread Pricing Address rebate retention in MCO and PBM contracts Rebates Are PBMs allowed to retain a portion of manufacturer rebates? Manufacturer admin fees? Address pharmacy provider Generic Effective Rate (GER) or Brand Effective Rate (BER) GER/BER recon
Slide 19: High Cost Drug Risk Mitigation
High Cost Drug Risk Mitigation
Slide 20: How do high cost gene therapies challenge Medicaid managed care programs?
How do high cost gene therapies challenge Medicaid managed care programs? a) Difficult to predict utilization or uptake rate b) Possible to overpay MCOs for utilization that doesn’t materialize c) Likely uneven distribution across MCOs d) Uncertainty of market availability timing e) All of the above
Slide 21: How do high cost gene therapies challenge Medicaid managed care programs?
How do high cost gene therapies challenge Medicaid managed care programs? a) Difficult to predict utilization or uptake rate b) Possible to overpay MCOs for utilization that doesn’t materialize c) Likely uneven distribution across MCOs d) Uncertainty of market availability timing e) All of the above
Slide 22: Next Level Managed Care Risk Mitigation
Next Level Managed Care Risk Mitigation Non-Risk Arrangement Partial Carve-Out Risk Corridor MCO processes claims Select drugs carved out of Target expense ratio for Select drugs excluded managed care select drugs from capitation FFS program processes Risk is shared if expenses State r
Slide 23: High Level Overview of Risk Mitigation Considerations
High Level Overview of Risk Mitigation Considerations General Managed Care Philosophy * * * * * * * Is there a risk of uneven What is the How important is How administratively distribution across prevalence of the care management to complex is the risk MCOs? condition being this drug or mitigation?
Slide 24: Drug Product Selection and Manufacturer Contracting
Drug Product Selection and Manufacturer Contracting • Preferred Drug Lists • Subscription Payment Models • Value Based Purchasing (VBP)
Slide 25: Preferred Drug Lists
Preferred Drug Lists
Slide 26: FFS Preferred Drug List (PDL)
FFS Preferred Drug List (PDL) Majority of States Have Implemented PDLs FFS PDL Implemented No FFS PDL Sources: Kaiser Family Foundation, Utah Health and Human Services website 26
Slide 27: Uniform PDL Applied to Managed Care
Uniform PDL Applied to Managed Care Majority of States Have Implemented PDLs Uniform PDL Implemented Uniform PDL for some classes No Uniform PDL N/A – No Managed Care Sources: Kaiser Family Foundation, State websites 27
Slide 28: Identify a challenge of implementing a PDL in managed care
Identify a challenge of implementing a PDL in managed care: a) 340B b) Pharmacy Provider Concerns c) Managed Care Adherence to PDL d) All of the above
Slide 29: Identify a challenge of implementing a PDL in managed care
Identify a challenge of implementing a PDL in managed care: a) 340B b) Pharmacy Provider Concerns c) Managed Care Adherence to PDL d) All of the above
Slide 30: Uniform PDL Adherence Challenges
Uniform PDL Adherence Challenges Misaligned Incentives Uniform PDLs often prefer brands over generics • MCO rates are set higher to accommodate higher gross cost • If MCO allows generic rather than brand, MCO costs are lower The MCO benefits financially by not complying with PDL policy 30
Slide 31: Next Level PDL Savings Opportunities
Next Level PDL Savings Opportunities Mechanisms to Maximize Uniform PDL Savings Establish PDL Monitor PDL Apply a penalty if Share PDL savings adherence adherence on a MCOs do not adhere and decision making expectations in monthly or to PDL with MCOs MCO contracts quarterly basis • Offer a performan
Slide 32: Subscription Payment Models
Subscription Payment Models
Slide 33: States have successfully negotiated subscription model payments for which disease state?
States have successfully negotiated subscription model payments for drugs treating which disease state? a) Spinal Muscular Atrophy b) Cystic Fibrosis c) Hepatitis C d) Hypertension
Slide 34: States have successfully negotiated subscription model payments for which disease state?
States have successfully negotiated subscription model payments for drugs treating which disease state? a) Spinal Muscular Atrophy b) Cystic Fibrosis c) Hepatitis C d) Hypertension
Slide 35: Next Level Subscription Payment Models
Next Level Subscription Payment Models Where could subscription models go next? Additional disease states: HIV/PrEP Combine drugs and Use outcome-based Diabetes contract with pharmacy metrics to drive Rare diseases (SMA, providers rather than subscription price Hemophilia) manufacturers
Slide 36: Value-Based Purchasing
i RY, Value-Based Purchasing
Slide 37: What recent regulatory change has the potential to increase VBP opportunities?
What recent regulatory change has the potential to increase VBP opportunities? a) Inflation Reduction Act b) CMS Multiple Best Prices Rule c) CMS Medicaid Quality Reporting Rule d) CMS Interoperability and Patient Access Final Rule
Slide 38: What recent regulatory change has the potential to increase VBP opportunities?
What recent regulatory change has the potential to increase VBP opportunities? a) Inflation Reduction Act b) CMS Multiple Best Prices Rule c) CMS Medicaid Quality Reporting Rule d) CMS Interoperability and Patient Access Final Rule
Slide 39: Building Blocks for Next Level VBP
Building Blocks for Next Level VBP Contracting vehicle in the form of a supplemental rebate contract which allows for VEHICLE varying rebate based on outcomes data and monitoring Data to evaluate outcomes must be available either via claims data or ACCESSIBLE DATA electronic health records MEASURABL
Slide 40: Prescription Payment Rate
Prescription Payment Rate • Pharmacy Reimbursement • Medical Provider Reimbursement • 340B Policy Options
Slide 41: Pharmacy Reimbursement
Pharmacy Reimbursement oe
Slide 42: Pharmacy Reimbursement Savings Opportunities
Pharmacy Reimbursement Savings Opportunities Ingredient Cost Savings Programs Dispensing Fee Maximum Allowable Cost (MAC) Programs Updated Cost of Dispensing Study • Drugs available as generic • Differentiate dispensing fees based on: - Prescription volume State-specific AAC programs - Location - Pr
Slide 43: Next Level Pharmacy Reimbursement Opportunities
Next Level Pharmacy Reimbursement Opportunities Ingredient Cost Dispensing Fee Innovative Cost Management Tie dispensing fee to quality • Maximum Allowable Cost (MAC) programs • Define process or outcome quality metrics - Specialty MAC • Offer higher dispensing fees to higher quality - Biosimilar MA
Slide 44: Medical Provider Reimbursement
Medical Provider Reimbursement
Slide 45: Medical Provider Reimbursement
Medical Provider Reimbursement Physician Administered Drugs: Common Policy Decision and Challenges Challenge: ASP + 6% rewards providers for using higher cost products Most Medicaid programs use Challenge: New IRA provisions increase Participate margin for biosimilars Medicare ASP based in rally rew
Slide 46: Next Level Medical Provider Reimbursement Options
Next Level Medical Provider Reimbursement Options Acquisition Cost Survey Set AAC rates for HCPCS codes Bundle Drugs with Services Establish MAC Rates AAC Explore bundled payments such as Align reimbursement with EAPG pharmacy channel MAC Bundled Establish MAC rates on drug Payments groups including
Slide 47: What other provider reimbursement changes have been successful in your state?
What other provider reimbursement changes have been successful in your state? ⓘ Start presenting to display the poll results on this slide.
Slide 48: 340B Policy Options
340B Policy | Options
Slide 49: EMPAA Attendees are Passionate about 340B
EMPAA Attendees are Passionate about 340B Responses to a Question Asked at the 2021 EMPAA Conference 49
Slide 50: Frequently Implemented 340B Policies
Frequently Implemented 340B Policies Add text here. Add text here. Add text here. Add lead in text here… Calculate HRSA Prohibit contract Retrospective ceiling and load pharmacies reconciliation of into point of sale (or prohibit 340B 340B claims with claims system entirely) covered entities
Slide 51: FFS Contract Pharmacies Policy
FFS Contract Pharmacies Policy Contract Pharmacies Allowed Contract Pharmacies Not Allowed District of Columbia • California — only hemophilia treatment centers have state-approved contract pharmacy arrangements Source: US Government Accountability Office. 340B Drug Discount Program: • New Hampshire
Slide 52: Next Level 340B Savings Opportunities
Next Level 340B Savings Opportunities 340B AAC Survey Apply 340B AAC • Survey 340B providers to requirement to Any 340B policy identify actual costs managed care change will • Audit price submitted on • Adjust capitation rates 340B claims elicit strong stakeholder response Identify 340B opportunitie
Slide 53: Utilization Improvement
Utilization Improvement • Utilization Management • Pharmacy Clinical Programs
Slide 54: Utilization Management
Utilization Management ==)
Slide 55: Utilization Management Best Practices
Utilization Management Best Practices Integrate medical data with Prior authorization at Partial first prior authorization process market entry fill programs • Use medical data to validate • Apply prior authorization edit to new • Identify drug classes with potential diagnoses of members requesting
Slide 56: Next Level Utilization Management
Next Level Utilization Management Trust but verify Align prior authorization Review managed care prior Prior authorization criteria across medical and authorization criteria vendor audit pharmacy benefits • Align prior authorization criteria for • Require approval of prior • Review data to identify
Slide 57: Pharmacy Clinical Programs
Pharmacy Clinical Programs
Slide 58: Next Level Pharmacist Clinical Services
Next Level Pharmacist Clinical Services Is it possible to pay pharmacies or pharmacists a monthly Move Away subscription fee for Medication Therapy medication or disease Maintain from Per-Rx or Management (MTM) Harness the Safety Per-Encounter Payment management? knowledge and Large potential, limit
Slide 59: Are You Ready to Take It to the Next Level?
Are You Ready to Take It to the Next Level? Who is this guy and what can we learn from him? Program Design Utilization Pitbull – known for “turning a negative into a Savings Drug positive” and always perservering Product Selection
Slide 60: Patience, passion and perseverance equals success
Patience, passion and perseverance equals success – Pitbull
Slide 61: True or False? State Medicaid programs are unlikely to encounter stakeholder resistance
True or False? State Medicaid programs are unlikely to encounter stakeholder resistance to a change in policy such as 340B provider payment.
Slide 62: True or False? State Medicaid programs are unlikely to encounter stakeholder resistance
True or False? State Medicaid programs are unlikely to encounter stakeholder resistance to a change in policy such as 340B provider payment. A: False
Slide 63: True or False? Managed care capitation rates and brand over generic preference
True or False? If managed care capitation rates are increased due to brand over generic preference on a PDL, the MCO benefits if utilization of the generic is tightly managed?
Slide 64: True or False? Managed care capitation rates and brand over generic preference
True or False? If managed care capitation rates are increased due to brand over generic preference on a PDL, the MCO benefits if utilization of the generic is tightly managed? A: False
Slide 65: Which of these does NOT represent a potential cost savings opportunity?
Which of these does NOT represent a potential cost savings opportunity for State Medicaid Programs? a) Expand MAC programs to encompass specialty drugs, biosimilars, and/or DME b) Establish 340B prices based on 340B provider survey c) Use an AWP or WAC discount guarantee instead of a MAC program for
Slide 66: Which of these does NOT represent a potential cost savings opportunity?
Which of these does NOT represent a potential cost savings opportunity for State Medicaid Programs? a) Expand MAC programs to encompass specialty drugs, biosimilars, and/or DME b) Establish 340B prices based on 340B provider survey c) Use an AWP or WAC discount guarantee instead of a MAC program for
Slide 67: Sara Drake
Sara Drake For more detailed information about this topic, MercerRx Government or to view the demo of MercerRx Passage, visit our website @ www.mercer-government.mercer.com/mercerrx-government.html 67