January/February 2013, Vol 6, No 1 by Dalia Buffery

The Peer-Reviewed Forum for Evidence in Benefit Design ™ January/February 2013

Volume 6, Number 1

For Payers, Purchasers, Policymakers, and Other Healthcare Stakeholders

EDITORIAL

Technology Trends in Healthcare David B. Nash, MD, MBA BUSINESS

Budget Impact Model: Epigenetic Assay Can Help Avoid Unnecessary Repeated Prostate Biopsies and Reduce Healthcare Spending ™

Wade Aubry, MD; Robert Lieberthal, PhD; Arnold Willis, MD; Grant Bagley, MD, JD; Simon M. Willis III, MS; Andrew Layton, BA Stakeholder Perspective by Kelly Huang, PhD

The Opportunity for Health Plans to Improve Quality and Reduce Costs by Embracing Primary Care Medical Homes Sarah Collins, MBA; Kevin B. “Kip” Piper, MA, FACHE; Gary Owens, MD Stakeholder Perspective by Jack E. Fincham, PhD, RPh REGULATORY

Medicare Part D and the Federal Employees Health Benefits Program: A Comparison of Prescription Drug Coverage Annesha Lovett, PharmD, MS, PhD Stakeholder Perspective by J. Warren Salmon, PhD Industry Trends

As Deadline Nears, Health Insurance Exchanges Making Progress, with Some Setbacks

EST. 2008

Low levels of platelet inhibition can raise some * questions 1-6

Factors that may impact platelet inhibition* for patients taking an oral antiplatelet include: • Genetic variation7-9 • Concomitant medications10-12 • Preexisting conditions that may impact antiplatelet response (eg, diabetes, obesity)13-15 • Patient noncompliance16-18 • Side effects that impact adherence19 *The relationship between inhibition of platelet aggregation and clinical activity has not been established.

Have you considered these factors when selecting an oral antiplatelet?

References: 1. Buonamici P, Marcucci R, Migliorini A, et al. J Am Coll Cardiol. 2007;49:2312-2317. 2. Matetzky S, Shenkman B, Guetta V, et al. Circulation. 2004;109:3171-3175. 3. Cuisset T, Frere C, Quilici J, et al. J Thromb Haemost. 2006;4:542-549. 4. Hochholzer W, Trenk D, Bestehorn H-P, et al. J Am Coll Cardiol. 2006;48:1742-1750. 5. Marcucci R, Gori AM, Paniccia R, et al. Circulation. 2009;119:237-242. 6. Bonello L, Tantry US, Marcucci R, et al; for the Working Group on High On-Treatment Platelet Reactivity. J Am Coll Cardiol. 2010;56:919-933. 7. Brandt JT, Close SL, Iturria SJ, et al. J Thromb Haemost. 2007;5:2429-2436. 8. Varenhorst C, James S, Erlinge D, et al. Eur Heart J. 2009;30:1744-1752. 9. Frere C, Cuisset T, Morange P-E, et al. Am J Cardiol. 2008;101:1088-1093. 10. Gilard M, Arnaud B, Cornily J-C, et al. J Am Coll Cardiol. 2008;51:256-260. 11. Farid NA, Payne CD, Small DS, et al. Clin Pharmacol Ther. 2007;81:735-741. 12. Yun KH, Rhee SJ, Park H-Y, et al. Int Heart J. 2010;51:13-16. 13. Angiolillo DJ, Fernandez-Ortiz A, Bernando E, et al. Diabetes. 2005;54:2430-2435. 14. Angiolillo DJ, Bernardo E, Ramírez C, et al. J Am Coll Cardiol. 2006;48:298-304. 15. Angiolillo DJ, Fernández-Ortiz A, Bernardo E, et al. J Invasive Cardiol. 2004;16:169-174. 16. Baran KW, Lasala JM, Cox DA, et al; for ARRIVE Investigators. Am J Cardiol. 2008;102:541-545. 17. Ergelen M, Uyarel H, Osmonov D, et al. Clin Appl Thromb Hemost. 2010;16:33-41. 18. Iakovou I, Schmidt T, Bonizzoni E, et al. JAMA. 2005;293:2126-2130. 19. Ho PM, Bryson CL, Rumsfeld JS. Circulation. 2009;119:3028-3035. Copyright © 2012 Daiichi Sankyo, Inc. and Lilly USA, LLC. All Rights Reserved. PG81531. Printed in USA. December 2012.

editorial board Editor-in-Chief

David B. Nash, MD, MBA Dean, the Dr Raymond C. and Doris N. Grandon Professor, Jefferson School of Population Health Philadelphia, PA Deputy Editors

Joseph D. Jackson, PhD Program Director, Applied Health Economics and Outcomes Research, Jefferson University School of Population Health, Philadelphia Laura T. Pizzi, PharmD, MPH, RPh Associate Professor, Dept. of Pharmacy Practice, Jefferson School of Pharmacy, Philadelphia Aging and Wellness

Eric G. Tangalos, MD, FACP, AGSF, CMD Professor of Medicine Mayo Clinic, Rochester, MN CANCER RESEARCH

Al B. Benson, III, MD, FACP, FASCO Professor of Medicine, Associate Director for Clinical Investigations Robert H. Lurie Comprehensive Cancer Center Northwestern University, IL Past Chair, NCCN Board of Directors Samuel M. Silver, MD, PhD, FASCO Professor of Internal Medicine, Hematology/Oncology Assistant Dean for Research, Associate Director, Faculty Group Practice, University of Michigan Medical School EMPLOYERS

Arthur F. Shinn, PharmD, FASCP President, Managed Pharmacy Consultants, LLC, Lake Worth, FL F. Randy Vogenberg, RPh, PhD Principal, Institute for Integrated Healthcare and Bentteligence, Sharon, MA ENDOCRINOLOGY

James V. Felicetta, MD Chairman, Dept. of Medicine Carl T. Hayden Veterans Affairs Medical Center, Phoenix, AZ Quang Nguyen, DO, FACP, FACE Adjunct Associate Professor Endocrinology Touro University Nevada EPIDEMIOLOGY Research

Joshua N. Liberman, PhD Executive Director, Research, Development & Dissemination, Sutter Health, Concord, CA GOVERNMENT

Kevin B. “Kip” Piper, MA, FACHE President, Health Results Group, LLC Washington, DC HEALTH INFORMATION TECHNOLOGY Kelly Huang, PhD President, HealthTronics, Inc. Austin, TX J. B. Jones, PhD, MBA Research Investigator, Geisinger Health System, Danville, PA Victor J. Strecher, PhD, MPH Professor and Director for Innovation and Social Entrepreneurship University of Michigan, School of Public Health and Medicine, Ann Arbor HEALTH OUTCOMES RESEARCH

Diana Brixner, RPh, PhD Professor & Chair, Dept. of Pharmacotherapy Executive Director, Outcomes Research Center, Director of Outcomes Personalized Health Care Program, University of Utah, Salt Lake City Joseph Couto, PharmD, MBA Clinical Program Manager Cigna Corporation, Bloomfield, CT

Steve Miff, PhD Senior Vice President VHA, Inc., Irving, TX Terri S. Moore, PhD, RPh, MBA Senior Manager, Product Development URAC Kavita V. Nair, PhD Associate Professor, School of Pharmacy University of Colorado at Denver, CO Gary M. Owens, MD President, Gary Owens Associates Glen Mills, PA Andrew M. Peterson, PharmD, PhD Dean, Mayes School of Healthcare Business and Policy, Associate Professor, University of the Sciences, Philadelphia, PA Sarah A. Priddy, PhD Director, Competitive Health Analytics Humana, Louisville, KY Timothy S. Regan, BPharm, RPh, CPh Executive Director, Strategic Accounts Xcenda, Palm Harbor, FL Vincent J. Willey, PharmD Associate Professor, Philadelphia School of Pharmacy, University of the Sciences Philadelphia, PA Paul Wilson Senior VP, Health Consumer Insights and Analytics, Blue Bell, PA David W. Wright, MPH President, Institute for Interactive Patient Care Bethesda, MD health & value promotion

Craig Deligdish, MD Hematologist/Oncologist Oncology Resource Networks, Orlando, FL Thomas G. McCarter, MD, FACP Chief Clinical Officer Executive Health Resources, PA Albert Tzeel, MD, MHSA, FACPE National Medical Director HumanaOne, Waukesha, WI MANAGED MARKETS

Jeffrey A. Bourret, RPh, MS, FASHP Senior Director, Medical Lead, Payer and Specialty Channel Strategy, Medical Affairs Pfizer Specialty Care Business Unit, PA Richard B. Weininger, MD Chairman, CareCore National, LLC Bluffton, SC PATIENT ADVOCACY

William E. Fassett, BSPharm, MBA, PhD, FAPhA Professor of Pharmacy Law & Ethics Dept. of Pharmacotherapy, College of Pharmacy Washington State University, Spokane, WA Mike Pucci Sr VP Commercial Operations and Business Development, PhytoChem Pharmaceuticals Lake Gaston, NC Personalized medicine

Amalia M. Issa, PhD, MPH Director, Program in Personalized Medicine & Targeted Therapeutics University of the Sciences, Philadelphia PHARMACOECONOMICs

Josh Feldstein President & CEO CAVA, The Center for Applied Value Analysis, Inc., Norwalk, CT Jeff Jianfei Guo, BPharm, MS, PhD Professor of Pharmacoeconomics & Pharmacoepidemiology, College of Pharmacy, Univ of Cincinnati, Medical Center, OH

American Health & Drug Benefits

www.AHDBonline.com

PHARMACY BENEFIT DESIGN

Joel V. Brill, MD, AGAF, CHCQM Chief Medical Officer, Predictive Health, Phoenix, AZ Leslie S. Fish, PharmD Vice President of Clinical Programs Fallon Community Health Plan, MA John Hornberger, MD, MS Cedar Associates, LLC CHP/PCOR Adjunct Associate, Menlo Park, CA Michael S. Jacobs, RPh Vice President, National Accounts Truveris, Inc., New York, NY Matthew Mitchell, PharmD, MBA Manager, Pharmacy Services SelectHealth, Salt Lake City, UT Paul Anthony Polansky, BSPharm, MBA Senior Field Scientist, Health Outcomes and PharmacoEconomics (HOPE) Endo Health Solutions, Chadds Ford, PA Christina A. Stasiuk, DO, FACOI Senior Medical Director Cigna, Philadelphia, PA Scott R. Taylor, BSPharm, MBA Executive Director, Industry Relations Geisinger Health System, Danville, PA POLICY & PUBLIC HEALTH

Joseph R. Antos, PhD Wilson H. Taylor Scholar in Health Care Retirement Policy, American Enterprise Institute Washington, DC Robert W. Dubois, MD, PhD Chief Science Officer National Pharmaceutical Council, Washington, DC Jack E. Fincham, PhD, RPh Professor of Pharmacy, Practice and Administration School of Pharmacy, University of Missouri Kansas City, MO Walid F. Gellad, MD, MPH Assistant Professor of Medicine, University of Pittsburgh, Staff Physician, Pittsburgh VA Medical Center, Adjunct Scientist, RAND Health Paul Pomerantz, MBA Executive Director Drug Information Association, Horsham, PA J. Warren Salmon, PhD Professor of Health Policy & Administration School of Public Health University of Illinois at Chicago Raymond L. Singer, MD, MMM, CPE, FACS Chief, Division of Cardiothoracic Surgery Vice Chair, Department of Surgery for Quality & Patient Safety and Outreach Lehigh Valley Health Network, PA RESEARCH & DEVELOPMENT

Frank Casty, MD, FACP Chief Medical Officer Senior VP, Clinical Development Medical Science Endo Pharmaceuticals, Chadds Ford, PA Michael F. Murphy, MD, PhD Chief Medical Officer and Scientific Officer Worldwide Clinical Trials King of Prussia, PA SPECIALTY PHARMACY

Atheer A. Kaddis, PharmD Senior Vice President Managed Markets/Clinical Services Diplomat Specialty Pharmacy, Flint, MI James T. Kenney, Jr, RPh, MBA Pharmacy Operations Manager Harvard Pilgrim Health Care Wellesley, MA Michael Kleinrock Director, Research Development IMS Institute for Healthcare Informatics Collegeville, PA

January/February 2012

Vol 6, No 1

January/February 2013

Volume 6, number 1

The Peer-Reviewed Forum for Evidence in Benefit Design ™

™

For Payers, Purchasers, Policymakers, and Other Healthcare Stakeholders

Table of Contents Publisher Nicholas Englezos nick@engagehc.com 732-992-1884 Editorial Director Dalia Buffery dalia@engagehc.com 732-992-1889 Associate Publisher Maurice Nogueira maurice@engagehc.com 732-992-1895 Associate Editor Lara J. Lorton lara@engagehc.com 732-992-1892 Editorial Assistant Jennifer Brandt jbrandt@the-lynx-group.com 732-992-1536 Executive Vice President Engage Managed Markets Chuck Collins ccollins@engagehc.com 732-992-1894 National Accounts Manager Zach Ceretelle zach@engagehc.com 732-992-1898 Senior Production Manager Lynn Hamilton Quality Control Director Barbara Marino Business Manager Blanche Marchitto

EDITORIAL

Technology Trends in Healthcare David B. Nash, MD, MBA

business

15 Budget Impact Model: Epigenetic Assay Can Help Avoid Unnecessary Repeated Prostate Biopsies and Reduce Healthcare Spending Wade Aubry, MD; Robert Lieberthal, PhD; Arnold Willis, MD; Grant Bagley, MD, JD; Simon M. Willis III, MS; Andrew Layton, BA 23 Stakeholder Perspective: Molecular Epigenetic Tests Can Improve Clinical Outcomes While Reducing Healthcare Costs Kelly Huang, PhD 30 The Opportunity for Health Plans to Improve Quality and Reduce Costs by Embracing Primary Care Medical Homes Sarah Collins, MBA; Kevin B. “Kip” Piper, MA, FACHE; Gary Owens, MD 38 Stakeholder Perspective: Enhancing Health Outcomes and Quality of Care with the Medical Home Model in Primary Care Jack E. Fincham, PhD, RPh

Founding Editor-in-Chief Robert E. Henry

Continued on page 10

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The median age of patients in the VISTA† trial was 71 years (range: 48-91).

Indication and Important Safety Information for VELCADE® (bortezomib) INDICATION VELCADE (bortezomib) is indicated for the treatment of patients with multiple myeloma. CONTRAINDICATIONS VELCADE is contraindicated in patients with hypersensitivity (not including local reactions) to bortezomib, boron, or mannitol, including anaphylactic reactions. VELCADE is contraindicated for intrathecal administration. WARNINGS, PRECAUTIONS, AND DRUG INTERACTIONS ▼ Peripheral neuropathy: Manage with dose modification or discontinuation. Patients with preexisting severe neuropathy should be treated with VELCADE only after careful risk-benefit assessment. ▼ Hypotension: Use caution when treating patients taking antihypertensives, with a history of syncope, or with dehydration.

▼ Cardiac toxicity: Worsening of and development of cardiac failure have occurred. Closely monitor patients with existing heart disease or risk factors for heart disease. ▼ Pulmonary toxicity: Acute respiratory syndromes have occurred. Monitor closely for new or worsening symptoms. ▼ Posterior reversible encephalopathy syndrome: Consider MRI imaging for onset of visual or neurological symptoms; discontinue VELCADE if suspected. ▼ Gastrointestinal toxicity: Nausea, diarrhea, constipation, and vomiting may require use of antiemetic and antidiarrheal medications or fluid replacement. ▼ Thrombocytopenia or Neutropenia: Monitor complete blood counts regularly throughout treatment. ▼ Tumor lysis syndrome: Closely monitor patients with high tumor burden. ▼ Hepatic toxicity: Monitor hepatic enzymes during treatment.

In treating multiple myeloma

What is the value of ® VELCADE (bortezomib)? ▼ Overall survival advantage ▼ Defined length of therapy ▼ Medication cost IF YOU DEFINE VALUE AS AN OVERALL SURVIVAL ADVANTAGE: VELCADE (bortezomib) combination delivered a >13-month overall survival advantage At 5-year median follow-up, VELCADE+MP* provided a median overall survival of 56.4 months vs 43.1 months with MP alone (HR=0.695 [95% CI, 0.57-0.85]; p<0.05)† At 3-year median follow-up, VELCADE+MP provided an overall survival advantage over MP that was not regained with subsequent therapies

IF YOU DEFINE VALUE AS DEFINED LENGTH OF THERAPY: Results achieved using VELCADE twice-weekly followed by weekly dosing for a median of 50 weeks (54 planned)1

IF YOU DEFINE VALUE AS MEDICATION COST: Medication cost is an important factor when considering overall drug spend. The Wholesale Acquisition Cost for VELCADE is $1,506 per 3.5-mg vial as of July 2012 When determining the value of a prescription drug regimen, it may be worth considering medication cost, length of therapy, and dosing regimens. This list is not all-inclusive; there are additional factors to consider when determining value for a given regimen

▼ Embryo-fetal risk: Women should avoid becoming pregnant while being treated with VELCADE. Advise pregnant women of potential embryo-fetal harm. ▼ Closely monitor patients receiving VELCADE in combination with strong CYP3A4 inhibitors. Avoid concomitant use of strong CYP3A4 inducers. ADVERSE REACTIONS Most commonly reported adverse reactions (incidence ≥20%) in clinical studies include nausea, diarrhea, thrombocytopenia, neutropenia, peripheral neuropathy, fatigue, neuralgia, anemia, leukopenia, constipation, vomiting, lymphopenia, rash, pyrexia, and anorexia. Please see Brief Summary for VELCADE on the next page of this advertisement. For Reimbursement Assistance, call 1-866-VELCADE (835-2233), Option 2, or visit VELCADEHCP.com.

Reference: 1. Mateos M-V, Richardson PG, Schlag R, et al. Bortezomib plus melphalan and prednisone compared with melphalan and prednisone in previously untreated multiple myeloma: updated follow-up and impact of subsequent therapy in the phase III VISTA trial. J Clin Oncol. 2010;28(13):2259-2266. *Melphalan+prednisone. † VISTA TRIAL: a randomized, open-label, international phase 3 trial (N=682) evaluating the efficacy and safety of VELCADE administered intravenously in combination with MP vs MP in previously untreated multiple myeloma. The primary endpoint was TTP. Secondary endpoints were CR, ORR, PFS, and overall survival. At a prespecified interim analysis (median follow-up 16.3 months), VELCADE+MP resulted in significantly superior results for TTP (median 20.7 months with VELCADE+MP vs 15.0 months with MP [p=0.000002]), PFS, overall survival, and ORR. Further enrollment was halted and patients receiving MP were offered VELCADE in addition. Updated analysis was performed.

Brief Summary INDICATIONS: VELCADE® (bortezomib) for Injection is indicated for the treatment of patients with multiple myeloma. VELCADE for Injection is indicated for the treatment of patients with mantle cell lymphoma who have received at least 1 prior therapy. CONTRAINDICATIONS: VELCADE is contraindicated in patients with hypersensitivity (not including local reactions) to bortezomib, boron, or mannitol, including anaphylactic reactions. VELCADE is contraindicated for intrathecal administration. WARNINGS AND PRECAUTIONS: Peripheral Neuropathy: VELCADE treatment causes a peripheral neuropathy that is predominantly sensory; however, cases of severe sensory and motor peripheral neuropathy have been reported. Patients with pre-existing symptoms (numbness, pain, or a burning feeling in the feet or hands) and/or signs of peripheral neuropathy may experience worsening peripheral neuropathy (including ≥Grade 3) during treatment with VELCADE. Patients should be monitored for symptoms of neuropathy, such as a burning sensation, hyperesthesia, hypoesthesia, paresthesia, discomfort, neuropathic pain or weakness. In the Phase 3 relapsed multiple myeloma trial comparing VELCADE subcutaneous vs intravenous, the incidence of Grade ≥2 peripheral neuropathy events was 24% for subcutaneous and 39% for intravenous. Grade ≥3 peripheral neuropathy occurred in 6% of patients in the subcutaneous treatment group, compared with 15% in the intravenous treatment group. Starting VELCADE subcutaneously may be considered for patients with pre-existing or at high risk of peripheral neuropathy. Patients experiencing new or worsening peripheral neuropathy during VELCADE therapy may require a decrease in the dose and/or a less dose-intense schedule. In the VELCADE vs dexamethasone phase 3 relapsed multiple myeloma study, improvement in or resolution of peripheral neuropathy was reported in 48% of patients with ≥Grade 2 peripheral neuropathy following dose adjustment or interruption. Improvement in or resolution of peripheral neuropathy was reported in 73% of patients who discontinued due to Grade 2 neuropathy or who had ≥Grade 3 peripheral neuropathy in the phase 2 multiple myeloma studies. The long-term outcome of peripheral neuropathy has not been studied in mantle cell lymphoma. Hypotension: The incidence of hypotension (postural, orthostatic, and hypotension NOS) was 8%. These events are observed throughout therapy. Caution should be used when treating patients with a history of syncope, patients receiving medications known to be associated with hypotension, and patients who are dehydrated. Management of orthostatic/postural hypotension may include adjustment of antihypertensive medications, hydration, and administration of mineralocorticoids and/or sympathomimetics. Cardiac Toxicity: Acute development or exacerbation of congestive heart failure and new onset of decreased left ventricular ejection fraction have occurred during VELCADE therapy, including reports in patients with no risk factors for decreased left ventricular ejection fraction. Patients with risk factors for, or existing, heart disease should be closely monitored. In the relapsed multiple myeloma study of VELCADE vs dexamethasone, the incidence of any treatment-related cardiac disorder was 8% and 5% in the VELCADE and dexamethasone groups, respectively. The incidence of adverse reactions suggestive of heart failure (acute pulmonary edema, pulmonary edema, cardiac failure, congestive cardiac failure, cardiogenic shock) was ≤1% for each individual reaction in the VELCADE group. In the dexamethasone group, the incidence was ≤1% for cardiac failure and congestive cardiac failure; there were no reported reactions of acute pulmonary edema, pulmonary edema, or cardiogenic shock. There have been isolated cases of QT-interval prolongation in clinical studies; causality has not been established. Pulmonary Toxicity: Acute Respiratory Distress Syndrome (ARDS) and acute diffuse infiltrative pulmonary disease of unknown etiology, such as pneumonitis, interstitial pneumonia, and lung infiltration have occurred in patients receiving VELCADE. Some of these events have been fatal. In a clinical trial, the first two patients given high-dose cytarabine (2 g/m2 per day) by continuous infusion with daunorubicin and VELCADE for relapsed acute myelogenous leukemia died of ARDS early in the course of therapy. There have been reports of pulmonary hypertension associated with VELCADE administration in the absence of left heart failure or significant pulmonary disease. In the event of new or worsening cardiopulmonary symptoms, consider interrupting VELCADE until a prompt, comprehensive, diagnostic evaluation is conducted. Posterior Reversible Encephalopathy Syndrome (PRES): Posterior Reversible Encephalopathy Syndrome (PRES; formerly termed Reversible Posterior Leukoencephalopathy Syndrome (RPLS)) has occurred in patients receiving VELCADE. PRES is a rare, reversible, neurological disorder, which can present with seizure, hypertension, headache, lethargy, confusion, blindness, and other visual and neurological disturbances. Brain imaging, preferably MRI (Magnetic Resonance Imaging), is used to confirm the diagnosis. In patients developing PRES, discontinue VELCADE. The safety of reinitiating VELCADE therapy in patients previously experiencing PRES is not known. Gastrointestinal Toxicity: VELCADE treatment can cause nausea, diarrhea, constipation, and vomiting, sometimes requiring use of antiemetic and antidiarrheal medications. Ileus can occur. Fluid and electrolyte replacement should be administered to prevent dehydration. Interrupt VELCADE for severe symptoms. Thrombocytopenia/Neutropenia: VELCADE is associated with thrombocytopenia and neutropenia that follow a cyclical pattern, with nadirs occurring following the last dose of each cycle and typically recovering prior to initiation of the subsequent cycle. The cyclical pattern of platelet and neutrophil decreases and recovery remained consistent over the 8 cycles of twice-weekly dosing, and there was no evidence of cumulative thrombocytopenia or neutropenia. The mean platelet count nadir measured was approximately 40% of baseline. The severity of thrombocytopenia was related to pretreatment platelet count. In the relapsed multiple myeloma study of VELCADE vs dexamethasone, the incidence of bleeding (≥Grade 3) was 2% on the VELCADE arm and <1% on the dexamethasone arm. Complete blood counts (CBC) should be monitored frequently during treatment with VELCADE. Platelet counts should be monitored prior to each dose of VELCADE. Patients experiencing thrombocytopenia may require change in the dose and schedule of VELCADE. Gastrointestinal and intracerebral hemorrhage has been reported in association with VELCADE. Transfusions may be considered. Tumor Lysis Syndrome: Tumor lysis syndrome has been reported with VELCADE therapy. Patients at risk of tumor lysis syndrome are those with high tumor burden prior to treatment. Monitor patients closely and take appropriate precautions. Hepatic Toxicity: Cases of acute liver failure have been reported in patients receiving multiple concomitant medications and with serious underlying medical conditions. Other reported hepatic reactions include hepatitis, increases in liver enzymes, and hyperbilirubinemia. Interrupt VELCADE therapy to assess reversibility. There is limited re-challenge information in these patients.

3822_26_milpro_fa1_hpr_ahdb.indd 2

Embryo-fetal: Pregnancy Category D. Women of reproductive potential should avoid becoming pregnant while being treated with VELCADE. Bortezomib administered to rabbits during organogenesis at a dose approximately 0.5 times the clinical dose of 1.3 mg/m2 based on body surface area caused post-implantation loss and a decreased number of live fetuses. ADVERSE EVENT DATA: Safety data from phase 2 and 3 studies of single-agent VELCADE 1.3 mg/m2/dose administered intravenously twice weekly for 2 weeks followed by a 10-day rest period in 1163 patients with previously-treated multiple myeloma (N=1008) and previously-treated mantle cell lymphoma (N=155) were integrated and tabulated. In these studies, the safety profile of VELCADE was similar in patients with multiple myeloma and mantle cell lymphoma. In the integrated analysis, the most commonly reported (≥10%) adverse reactions were nausea (49%), diarrhea NOS (46%), fatigue (41%), peripheral neuropathies NEC (38%), thrombocytopenia (32%), vomiting NOS (28%), constipation (25%), pyrexia (21%), anorexia (20%), anemia NOS (18%), headache NOS (15%), neutropenia (15%), rash NOS (13%), paresthesia (13%), dizziness (excl vertigo 11%), and weakness (11%). Eleven percent (11%) of patients experienced at least 1 episode of ≥Grade 4 toxicity, most commonly thrombocytopenia (4%) and neutropenia (2%). A total of 26% of patients experienced a serious adverse reaction during the studies. The most commonly reported serious adverse reactions included diarrhea, vomiting, and pyrexia (3% each), nausea, dehydration, and thrombocytopenia (2% each), and pneumonia, dyspnea, peripheral neuropathies NEC, and herpes zoster (1% each). In the phase 3 VELCADE+melphalan and prednisone study in previously untreated multiple myeloma, the safety profile of VELCADE administered intravenously in combination with melphalan/prednisone is consistent with the known safety profiles of both VELCADE and melphalan/prednisone. The most commonly reported adverse reactions in this study (VELCADE+melphalan/prednisone vs melphalan/prednisone) were thrombocytopenia (48% vs 42%), neutropenia (47% vs 42%), peripheral neuropathy (46% vs 1%), nausea (39% vs 21%), diarrhea (35% vs 6%), neuralgia (34% vs <1%), anemia (32% vs 46%), leukopenia (32% vs 28%), vomiting (26% vs 12%), fatigue (25% vs 14%), lymphopenia (23% vs 15%), constipation (23% vs 4%), anorexia (19% vs 6%), asthenia (16% vs 7%), pyrexia (16% vs 6%), paresthesia (12% vs 1%), herpes zoster (11% vs 3%), rash (11% vs 2%), abdominal pain upper (10% vs 6%), and insomnia (10% vs 6%). In the phase 3 VELCADE subcutaneous vs intravenous study in relapsed multiple myeloma, safety data were similar between the two treatment groups. The most commonly reported adverse reactions in this study were peripheral neuropathy NEC (37% vs 50%), thrombocytopenia (30% vs 34%), neutropenia (23% vs 27%), neuralgia (23% vs 23%), anemia (19% vs 23%), diarrhea (19% vs 28%), leukopenia (18% vs 20%), nausea (16% vs 14%), pyrexia (12% vs 8%), vomiting (9% vs 11%), asthenia (7% vs 16%), and fatigue (7% vs 15%). The incidence of serious adverse reactions was similar for the subcutaneous treatment group (20%) and the intravenous treatment group (19%). The most commonly reported SARs were pneumonia and pyrexia (2% each) in the subcutaneous treatment group and pneumonia, diarrhea, and peripheral sensory neuropathy (3% each) in the intravenous treatment group. DRUG INTERACTIONS: Bortezomib is a substrate of cytochrome P450 enzyme 3A4, 2C19 and 1A2. Co-administration of ketoconazole, a strong CYP3A4 inhibitor, increased the exposure of bortezomib by 35% in 12 patients. Monitor patients for signs of bortezomib toxicity and consider a bortezomib dose reduction if bortezomib must be given in combination with strong CYP3A4 inhibitors (eg, ketoconazole, ritonavir). Co-administration of omeprazole, a strong inhibitor of CYP2C19, had no effect on the exposure of bortezomib in 17 patients. Co-administration of rifampin, a strong CYP3A4 inducer, is expected to decrease the exposure of bortezomib by at least 45%. Because the drug interaction study (n=6) was not designed to exert the maximum effect of rifampin on bortezomib PK, decreases greater than 45% may occur. Efficacy may be reduced when VELCADE is used in combination with strong CYP3A4 inducers; therefore, concomitant use of strong CYP3A4 inducers is not recommended in patients receiving VELCADE. St. John’s wort (Hypericum perforatum) may decrease bortezomib exposure unpredictably and should be avoided. Co-administration of dexamethasone, a weak CYP3A4 inducer, had no effect on the exposure of bortezomib in 7 patients. Co-administration of melphalan-prednisone increased the exposure of bortezomib by 17% in 21 patients. However, this increase is unlikely to be clinically relevant. USE IN SPECIFIC POPULATIONS: Nursing Mothers: It is not known whether bortezomib is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from VELCADE, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use: The safety and effectiveness of VELCADE in children has not been established. Geriatric Use: No overall differences in safety or effectiveness were observed between patients ≥age 65 and younger patients receiving VELCADE; but greater sensitivity of some older individuals cannot be ruled out. Patients with Renal Impairment: The pharmacokinetics of VELCADE are not influenced by the degree of renal impairment. Therefore, dosing adjustments of VELCADE are not necessary for patients with renal insufficiency. Since dialysis may reduce VELCADE concentrations, VELCADE should be administered after the dialysis procedure. For information concerning dosing of melphalan in patients with renal impairment, see manufacturer’s prescribing information. Patients with Hepatic Impairment: The exposure of bortezomib is increased in patients with moderate and severe hepatic impairment. Starting dose should be reduced in those patients. Patients with Diabetes: During clinical trials, hypoglycemia and hyperglycemia were reported in diabetic patients receiving oral hypoglycemics. Patients on oral antidiabetic agents receiving VELCADE treatment may require close monitoring of their blood glucose levels and adjustment of the dose of their antidiabetic medication. Please see full Prescribing Information for VELCADE at VELCADEHCP.com.

VELCADE, MILLENNIUM and are registered trademarks of Millennium Pharmaceuticals, Inc. Other trademarks are property of their respective owners. Millennium Pharmaceuticals, Inc., Cambridge, MA 02139 Copyright © 2012, Millennium Pharmaceuticals, Inc. All rights reserved. Printed in USA

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The Peer-Reviewed Forum for Evidence in Benefit Design ™

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Table of Contents

(Continued)

REGULATORY

47 Medicare Part D and the Federal Employees Health Benefits Program: A Comparison of Prescription Drug Coverage Annesha Lovett, PharmD, MS, PhD 58 Stakeholder Perspective: Medicare Part D and the Federal Employees Health Benefits Program J. Warren Salmon, PhD DEPARTMENTs

14 Exploring Men’s Willingness to Pay for Prostate Cancer Screening to Avoid Unnecessary Biopsy and Treatment Rosemary Frei, MSc INDUSTRY TRENDS 25 As Deadline Nears, Health Insurance Exchanges Making Progress, with Some Setbacks By Dalia Buffery, MA, ABD 42

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For Payers, Purchasers, Policymakers, and Other Healthcare Stakeholders

HIPAA Privacy and Security Regulations Updated Ross D. Margulies, JD, MPH; Jayson Slotnik, JD, MPH

43 The Role of Personalized Medicine in the Management of Patients with Breast Cancer Phoebe Starr

American Health & Drug Benefits, ISSN 1942-2962 (print); ISSN 1942-2970 (online), is published 8 times a year by Engage Healthcare Communications, LLC, 1249 South River Rd, Suite 202A, Cranbury, NJ 08512. Copyright © 2013 by Engage Healthcare Communications, LLC. All rights reserved. American Health & Drug Benefits and The Peer-Reviewed Forum for Evidence in Benefit Design are trademarks of Engage Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any informational storage and retrieval system, without written permission from the Publisher. Printed in the United States of America. Address all editorial correspondence to: editorial@engagehc.com Telephone: 732-992-1892 Fax: 732-992-1881 American Health & Drug Benefits 1249 South River Rd, Suite 202A, Cranbury, NJ 08512 The ideas and opinions expressed in American Health & Drug Benefits do not necessarily reflect those of the Editorial Board, the Editors, or the Publisher. Publication of an advertisement or other product mentioned in American Health & Drug Benefits should not be construed as an endorsement of the product or the manufacturer’s claims. Readers are encouraged to contact the manufacturers about any features or limitations of products mentioned. Neither the Editors nor the Publisher assume any responsibility for any injury and/or damage to persons or property arising out of or related to any use of the material mentioned in this publication. For permission to reuse material from American Health & Drug Benefits (ISSN 1942-2962), please access www. copyright.com <http://www.copyright. com/> or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400.

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EDITORIAL EDITORIAL

Technology Trends in Healthcare David B. Nash, MD, MBA Editor-in-Chief, American Health & Drug Benefits Jefferson School of Population Health, Philadelphia, PA

have been fascinated by new technology ever since our parents took my younger brother and me to the amazing 1964 World’s Fair in Queens, NY. We especially loved the “Theatre of Tomorrow” exhibit sponsored by General Electric. I can still see the futuristic family room rotating in front of my eyes. Perhaps that is why I am always drawn to the Technology Quarterly section in the British news magazine, The Economist. It provides a broad overview of technology trends across many different industries. I am sure that most of our readers would agree that trying to keep tabs on technology in healthcare is nearly impossible. Often we will turn to junior staff to help us leverage the benefits of the spectrum of clinical, communication, and data management tools. A recent report in the Technology Quarterly section of the The Economist focused on 3 areas within healthcare that caught my attention.1

Imagine all of the potential healthcare ramifications of this kind of consumer electronic gesture-based system. We could walk around the hospital and pull down charts “from the ceiling,” as it were, and through gestures, communicate, write notes, and send information to other caregivers. “Robot-assisted surgery today is dominated by the da Vinci Surgical System,” that report suggests.1 The da Vinci system is a special device that scales down and translates a surgeon’s hand movements to facilitate surgery through tiny incisions. According to that report, “almost 2,000 da Vincis have been made, and they are used in about 200,000 operations a year around the world, most commonly hysterectomies and prostate removals.”1 However, what I do not fully appreciate is that the da Vinci system is based on a proprietary-closed software system. It is costly to acquire, and researchers are not

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able to experiment with modifications to the software. In response to the curiosity of researchers (and the desire to make something good even better), Raven was born. Originally developed for the US Army by Blake Hannaford, PhD, University of Washington, Seattle, and Jacob Rosen, PhD, University of California in Santa Cruz, the Raven is light and (relatively) cheap. More important, it uses open-source software. Its Linuxbased operating system allows researchers to experiment and collaborate to modify and improve the original code. Ownership of the resulting innovations will be retained by the researchers, but their results will be made available in an online repository.1 Another area in that report that caught my eye involves “gesture recognition systems” that allow us to use our body instead of carrying around a range of portable electronic devices. According to researcher Chris Harrison, a PhD student at the Human-Computer Interaction Institute at Carnegie Mellon University in Pittsburgh, this may become the “shape of things to come.”1 Harrison’s prototype for gesture recognition systems is called Armura. One project under the Armura heading is OmniTouch. OmniTouch combines an array of sensors with a small shoulder-mounted projector. The genius of Armura is that it takes this idea a step further, by mounting the sensors and the projector in the ceiling. This frees the user from the need to carry anything, and also provides a “convenient place from which to spot his gestures.”1 OmniTouch would allow us to dial a phone from a hologram projection on our hand. Imagine all of the potential healthcare ramifications of this kind of consumer electronic gesture-based system. We could walk around the hospital and pull down charts “from the ceiling,” as it were, and through gestures, communicate, write notes, and send information to other caregivers. This would be the ultimate convenient rounding system. The third area that has fascinated me for the past couple of years is the idea of “self-tracking,” also known as “quantified self.” Those involved in self-tracking track and share with other people data about their rapid eye movement sleep, the number of miles they jog per

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EDITORIAL

day, the total calories they consume, and the like. The Economist reports on new players (ie, companies that are all based in San Francisco) and developments in the “self-tracking” world1: • Jawbone has released Up, a wristband that communicates with an iPhone and can also measure physical activity and sleep patterns • Basis is about to launch a wristwatch-type device capable of measuring heart rate, skin conductance, and sleep patterns, all of which can then be displayed on a health dashboard • And finally, GreenGoose has devised a tiny motion sensor that can be attached to everyday items, sending a wireless signal to a base station whenever the item is used; this sensor, for example, can be attached to a toothbrush, watering can, collar of the dog, or other potential health-related activities that can become a “platform for the gamification of everyday activities.” I am fascinated by all of the potential prevention and wellness activities that can be enhanced via the technology from companies like Jawbone, Basis, and Green

Goose. Data that have been collected can serve as the basis for a very comprehensive conversation with primary care physicians about a patient’s commitment to fitness, appropriate diet, and other prevention and wellness activities. This practical use of technology has the potential to transform the patient–physician relationship. My future grandchildren will not be attending a World’s Fair in person anytime soon; they will, instead, be logging on and participating in a virtual way, led by some of the companies mentioned above. The potential to improve our daily life, enhanced with the appropriate technology, is nearly limitless. We can start with enhanced adherence and compliance programs and build a prevention platform and a healthcare dashboard today. I am confident that there are pharmacists, nurses, and clinicians of all types tinkering in their garages right now. As always, I am interested in your views, and you can reach me by e-mail at david.nash@jefferson.edu. Please also visit my blog at http://nashhealthpolicy.blogspot.com. Reference

1. Technology Quarterly. The Economist. March 3, 2012:3-24.

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Exploring Men’s Willingness to Pay for Prostate Cancer Screening to Avoid Unnecessary Biopsy and Treatment By Rosemary Frei, MSc

utch researchers have peered into the minds and wallets of a group of men aged 55 to 75 years to determine what they are willing to trade for a reduced risk of prostate cancer–related death or to avoid unnecessary procedures and treatment. Men with more education had a lower probability of opting for prostate cancer screening. Furthermore, in aggregate, the men were willing to lose 2% of risk reduction in mortality related to prostate cancer or to pay on average €188 (in 2010 Euros; equivalent to $245 in 2010 US dollars) annually for a 10% reduced risk of unnecessary biopsy or treatment. “Physicians should be aware that men, particularly those with less education, may overestimate the benefit of prostate cancer screening, due to numeracy problems...and that therefore tailored prostate cancer screening programs may result in a better-informed shared decision-making for screening,” wrote Esther W. de Bekker-Grob, PhD, a researcher and health economist at Erasmus Medical Center, Rotterdam, the Netherlands, and her colleagues (de Bekker-Grob EW, et al. Br J Cancer. 2013 Jan 29 [Epub ahead of print]).

The men were also willing to trade 1.8% of their reduced mortality risk for a 10% reduction in the probability of an unnecessary biopsy, and a 4.6% reduced risk of prostate cancer–related death for a 2-year screening interval rather than a 4-year screening interval. “Increasing knowledge on overdiagnosis and overtreatment, especially for men with lower educational levels, is warranted to prevent unrealistic expectations from prostate cancer screening,” she continued. The team formulated 2 versions of a questionnaire containing 16 choice sets on prostate cancer screening. These were based on the prostate cancer screening literature and interviews with 8 prostate cancer experts. A total of 459 men (average age, 63.3 years) from

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southwest Holland responded to the questionnaires. The researchers divided the men into 3 groups: • Most men in the first group had a lower educational level, did not have anxiety or depression, and were willing to pay for prostate cancer screening • Most men in the second group also had a lower educational level and did not have anxiety or depression, but they were not willing to pay for screening • The third group largely comprised men who had a higher educational level, had anxiety or depression, and were not willing to pay for prostate cancer screening. The men in all 3 groups indicated that a reduction in the risk of developing prostate cancer, a reduction in the risk of unnecessary treatment and biopsy, and costs are all important. Those in the first group had a preference for annual or biennial screening, those in the second group did not have a preference for shorter or for longer screening intervals, and members of the third group preferred screening every 2 years versus screening every 4 years.

Willingness to Pay When all 3 groups were combined, the men were willing to pay an average cost of: • €188 (or $245 US) for a 10% reduction in prostate cancer–related death • €33 ($43 US) annually for a 10% reduction in the risk of an unnecessary prostate biopsy • €38 ($50 US) annually for a 10% decrease in the risk of undergoing unnecessary treatment • €87 ($115 US) annually to access a prostate cancer screening program with a 2-year interval rather than a 4-year interval. In addition, the men were willing to exchange 2% of the reduced risk of prostate cancer mortality for a 10% reduction in unnecessary treatment. The men were also willing to trade 1.8% of their reduced mortality risk for a 10% reduction in the probability of an unnecessary biopsy, and a 4.6% reduced risk of prostate cancer–related death for a 2-year screening interval rather than a 4-year screening interval. n

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Vol 6, No 1

BUSINESS

Original Research

Budget Impact Model: Epigenetic Assay Can Help Avoid Unnecessary Repeated Prostate Biopsies and Reduce Healthcare Spending

Wade Aubry, MD; Robert Lieberthal, PhD; Arnold Willis, MD; Grant Bagley, MD, JD; Simon M. Willis III, MS; Andrew Layton, BA Background: The diagnosis of prostate cancer involves invasive, sometimes harmful, procedures that can entail negative quality-of-life implications to individuals and high additional costs to the US healthcare system when these procedures result in retesting and iatrogenic harms. It is estimated that $1.86 billion is spent annually on prostate-specific antigen (PSA) testing alone. An advanced epigenetic molecular diagnostic test that uses methylation-specific polymerase chain reaction to assess the DNA methylation status of GSTP1, APC, and RASSF1 genes associated with oncogenesis enables a higher degree of accuracy (previously unattainable through prostate biopsy procedures alone) and produces clinical, financial, and health benefits by reducing the number of medically unnecessary and costly repeated biopsies that are part of today’s standard of care. Objectives: The purpose of this study is to quantify, using a budget impact model, the effect of a relatively new epigenetic assay on healthcare costs for commercial health plans that reimburse for the assay, by avoiding unnecessary repeated prostate biopsy procedures. Methods: A budget impact model was developed to test the hypothesis that the epigenetic assay can produce cost-saving benefits to health plans, as well as clinical benefits to urologists and patients with prostate cancer, by providing guidance on how to offer patients more appropriate, and less costly, care. The budget impact model is presented from the perspective of a hypothetical commercial health plan, and direct costs are calculated over a 1-year time horizon, using 2013 Medicare fee-for-service rates. Using a plan of 1 million members, the model compares 1-year costs in a “reference scenario,” in which the epigenetic assay is not used for the screening and diagnosis of prostate cancer, to costs in a “new scenario,” in which the epigenetic assay is used to distinguish true-negative prostate biopsy results from false-negative biopsy results. Results: Based on this analysis, administering the epigenetic assay to patients with histopathologically negative biopsies would result in a reduction of 1106 unnecessary biopsies for a health plan with 1 million members. The total 1-year cost of repeated prostate cancer biopsies to the health plan was found to be $2,864,142 in the reference scenario and $2,333,341 in the new scenario. This translates to a total budget impact, or an annual savings, of $530,801 to the plan. The total diagnostic cost was calculated to be $2584 per patient in the new scenario (using the genetic assay) compared with $3172 per patient in the reference scenario (that did not use the assay), resulting in a savings of $588 per patient management. Conclusion: This analysis shows that the net cost to a commercial health plan with 1 million members would be reduced by approximately $500,000 if patients with histopathologically negative biopsies were managed with the use of the epigenetic assay to differentiate patients who should undergo repeated biopsy and those who should not. Using this genetic-based assay can save costs to health plans and to the US healthcare and improve the clinical management of patients with elevated PSA levels.

Stakeholder Perspective, page 23

Am Health Drug Benefits. 2013;6(1):15-24 www.AHDBonline.com Disclosures are at end of text

Dr Aubry is Associate Clinical Professor of Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, and Senior Medical Director, Quorum Consulting, San Francisco, CA; Dr Lieberthal is Assistant Professor, Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, PA; Dr A. Willis is Associate Dean of Clinical Sciences and Professor of Urology, Aureus University School of Medicine, Oranjestad, Aruba; Dr Bagley is Senior Advisor, HillCo HEALTH, Washington, DC; Mr S.M. Willis is third-year medical student, Aureus University School of Medicine, Oranjestad, Aruba; and Mr Layton is Director, Information Technology, Quorum Consulting, San Francisco, CA.

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BUSINESS

rostate cancer is the most frequently detected cancer in men, and 1 of 6 men will be diagnosed with prostate cancer during their lifetime based on Medicare enrollment data.1 In the United States, approximately 19 million men annually are screened by prostate-specific antigen (PSA) testing,2 resulting in approximately 4.7 million abnormal PSA test results (≥4.0 ng/mL)3 leading to approximately 1.3 million biopsy procedures.4 According to the National Cancer Institute, 241,740 men are diagnosed with prostate cancer annually, and 28,170 prostate cancer–related deaths were reported in 2012.5 Although some forms of prostate cancer are deadly, many forms are low grade and can be managed by active surveillance. Aggressive variants of prostate cancer can be one of the deadliest cancers in men, and accurate diagnosis and follow-up remain a challenge and come at a considerable cost to the US healthcare system.

Clinical Burden Despite the recent controversy that was raised by the US Preventive Services Task Force (USPSTF) findings on PSA testing, leading to their recommendations to stop routine PSA-based screening,6 the American Urological Association (AUA) continues to recommend the PSA blood test, along with digital rectal examination (DRE), for screening men at risk for prostate cancer. Screening has led to a shift of detecting earlier-stage disease, resulting in an increased likelihood for curative treatment. If screening is eliminated, urologists fear an increased incidence of advanced cancers and an increase in healthcare costs to effectively treat these patients.7 Today, urologists typically perform a biopsy for high-risk patients with a rising PSA and for patients with a PSA level ≥4.0 ng/mL, obtaining approximately 10 to 12 needle-core tissue samples according to the current standard of care.8,9 Of note, an abnormal PSA result can often be caused by factors other than cancer, including infection, inflammation, or other benign conditions, such as benign prostatic hyperplasia. This leads to the inclusion of many men with no cancer among those who are being subjected to prostate biopsies (ie, false-positive PSA screening). The rate of cancer detection in men undergoing prostate biopsies is approximately 30%, and approximately 75% of men who have undergone biopsies have negative prostate biopsy results.2,3 An elevated PSA and/or abnormal DRE identify men at high risk for prostate cancer, and, as a result, many of these men will undergo a biopsy procedure. However, because of the nature of random and limited sampling of the prostate, many cancers are undetected by histopathologic review. Studies by urology and pathology opinion leaders report that initial prostate biopsy histopathology has a 20% to 30% false-negative rate.8,10,11

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Key Points The diagnosis of prostate cancer involves invasive procedures that can have negative clinical implications for patients and add costs to health plans and the US healthcare system. ➤ The appropriate use of PSA testing remains controversial, because elevated PSA levels can be caused by conditions unrelated to prostate cancer. ➤ Nevertheless, many men with benign conditions and elevated PSA levels undergo repeated prostate biopsies, which may be unnecessary, because of low risk of prostate cancer. ➤ A recent genetic-based assay has shown 90% negative predictive value in differentiating men with elevated PSA levels who should undergo a biopsy and those who should not. ➤ Applying a budget impact analysis to a hypothetical 1-million-member health plan based on current evidence-based data, the use of this assay would reduce the number of unnecessary biopsies in this plan by 1106 annually and save the plan $530,142. ➤ In line with the increasing focus on personalized medicine in oncology, using a genetic-based test to select appropriate candidates for prostate cancer biopsies can limit the number of unnecessary biopsies performed and save costs to payers and to the US healthcare system. ➤

Given these reported false-negative rates for histology, many patients with persistently elevated PSA values are at risk for occult cancer. This uncertainty poses a diagnostic dilemma, resulting in many men receiving 2, 3, and sometimes 4 repeated biopsy procedures.12-14 Repeated biopsies expose patients to the discomfort and risk of complications associated with this invasive procedure. Complications include infections, prostatitis, cystitis, sepsis, endocarditis, hypotension, gastrointestinal hemorrhage, hematuria, and urinary symptoms. Recently, antibiotic resistance has also been cited as a growing concern.1

Economic Burden Repeated biopsies also generate high medical costs. Approximately $1.86 billion is spent annually on PSA tests alone.2,15 More than $4 billion is spent annually on therapies for prostate cancer, and this amount is expected to increase to $8.7 billion by the year 2019.16 Molecular Testing With such high costs to the US healthcare system, as well as negative quality-of-life implications to patients,

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January/February 2013

Vol 6, No 1

Epigenetic Assay: Screening for Prostate Cancer

the AUA has called for new biomarkers for the improved diagnosis and treatment of prostate cancer.17 With the growing movement toward personalized medicine, the application of molecular testing to improve cancer detection and the management of patients represents an evolution in oncology.2,18 Epigenetic assays, in particular, have been reported to improve on the accuracy of prostate biopsies and histopathologic review.2,8 (Epigenetic refers to gene regulatory mechanisms; epigenetic assays are based on the differences in the chromatin structure of actively and silent genes.) In a recent multicenter, blinded study, such an epigenetic assay (ie, ConfirmMDx for Prostate Cancer) was used to detect occult cancer in histopathologically negative prostate biopsies.8 The assay was performed using multiplex methylation-specific polymerase chain reaction to assess the DNA methylation status of the GSTP1, APC, and RASSF1 genes associated with the presence of cancer in residual negative prostate biopsy tissue samples.3,8,10 Using this advanced molecular diagnostic test allows for a higher degree of accuracy that was previously unattainable through prostate biopsy procedures alone. By detecting epigenetic changes that are known to be associated with oncogenesis progression, in cancer lesions or in neighboring cells (ie, field effect), these biomarkers aid in the identification of occult prostate cancer. This field effect accounts for improved detection in adjacent, benign-looking tissue, providing a higher negative predictive value than standard histopathology alone.19,20 The test results of this new epigenetic assay can guide urologists in decisions regarding the need to repeat a biopsy in patients with a previously negative biopsy who are still considered at risk for prostate cancer.8

A Budget Impact Analysis A budget impact model was developed to assess whether the epigenetic assay can also produce financial benefits, beyond the reported clinical and health benefits. The model was designed to quantify the impact on the costs associated with repeated biopsies used for the screening and diagnosis of prostate cancer, and to test the hypothesis that the epigenetic assay produces a beneficial reduction in costs to commercial health plans, while providing improved guidance for patient management that leads to less invasive and less costly care. This type of analysis is an essential tool for healthcare managers and policymakers budgeting and instituting coverage decisions for prostate cancer diagnostics. Methods Study Design The budget impact model is presented from the perspective of a hypothetical commercial health plan, and

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direct costs are calculated over a 1-year time horizon, using Medicare fee-for-service (FFS) rates.21,22 The membership of this health plan is based on an assumed size of 1 million members, half of whom are males. The membership is distributed among age categories according to US population data.23

The cost analysis was based on total costs of 1 year in the course of prostate cancer screening and evaluation through prostate biopsy. Costs to the health plan are assumed to be equal to the Medicare FFS rates, which provide a conservative benchmark for reimbursement rates paid for by other health plans. The modelâ&#x20AC;&#x2122;s base-case analysis was conducted for a hypothetical plan using patient age-groups between ages 40 and 64 years (similar to those in commercial health plans). An additional sensitivity analysis was conducted for a hypothetical plan consisting of patients aged â&#x2030;Ľ65 years (similar to a Medicare health plan), using methods identical to the base case, with the exception of the patient ages and corresponding PSA rates. Biopsies and costs for patients younger than age 40 years or older than age 74 years were not included in the analysis. The model screens the population to select patients who may receive a biopsy to test for the presence of prostate cancer. It then selects a specific subpopulation of those men, which are individuals who may receive a repeat biopsy. For men at risk of undergoing a repeated biopsy, the model allows for the simulation of the current (reference scenario) and a counterfactual reality (new scenario). In the reference scenario, the model uses current clinical patterns of care to simulate the treatment of men at risk of prostate cancer in the reference scenario; a molecular assay was not utilized for prostate cancer detection. In the new scenario, men at risk for repeated biopsy are evaluated with the epigenetic assay, and those with a negative DNA methylation test result are spared a repeat of the biopsy, thereby reducing the number of unnecessary procedures. The cost analysis was based on total costs of 1 year in the course of prostate cancer screening and evaluation through prostate biopsy. Costs to the health plan are assumed to be equal to the Medicare FFS rates, which provide a conservative benchmark for reimbursement rates paid for by other health plans. In the reference

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Figure P otential Patients for Epigenetic Assay in a 1-MillionMember Health Plan Members in commercial health plan (age, 0-64 yrs) N = 1 million Excluded patients 500,000 females Male patients (all ages) N = 500,000 Excluded men (age <40 yrs) N = 313,502 Male patients (age, 40-64 yrs) N = 186,498

Number of men screened (PSA) N = 41,197 Excluded patients 38,396 did not have prostate biopsy Men who had prostate biopsy N = 2801 Excluded patients 700 diagnosed with prostate cancer Men at risk for repeated biopsy N = 2101

PSA indicates prostate-specific antigen.

scenario, the health plan incurs the costs of 1 or several repeated biopsies and the associated iatrogenic costs. In the new scenario, the health plan incurs the cost of an additional diagnostic test performed on the residual prostate tissue from the original sample plus the cost for repeated biopsies and associated iatrogenic costs on patients who had positive test results. The model assumes that the epigenetic assay would be used for all men meeting the assayâ&#x20AC;&#x2122;s eligibility requirements, including an abnormal DRE, an elevated PSA level, and a negative prostate biospy. Both scenarios

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Data Sources The PubMed database was searched for published clinical and pharmacoeconomic studies to assign values to the clinical and cost parameters used in the model. Studies were identified in PubMed that reflect current practice patterns of 10 to 12 core prostate biopsies in contrast to older studies that were based on sextant biopsy practice. For cost parameters, a combination of published literature cross-referenced to Medicare payment rates was used. Parameters pertaining to the accuracy and outcomes of the assay (including the assayâ&#x20AC;&#x2122;s sensitivity and specificity, and the positive and negative predictive values) were cited from the MATLOC clinical trial.8 Sample Selection PSA screening rates in US males vary by age, ranging from approximately 8% to almost 50%.24 Of all men screened for PSA, 6.8% are assumed to undergo biopsy based on a PSA of at least 4 ng/mL.25 These PSA and biopsy rates were applied to the hypothetical commercial health plan. Of the hypothetical plan, patients aged 40 to 64 years were selected, using demographic data from the US Census Bureau 2010, for inclusion in the model. Applying the national PSA screening and biopsy rates to the hypothetical commercial population yields a total of 2801 men undergoing a prostate biopsy. A total of 2101 men were deemed at risk for repeated biopsy based on a prostate cancer detection rate of 25% (Figure).25

Excluded patients 145,301 not screened (PSA)

calculate a total cost and a plan budget impact, expressed on a per-member per-month (PMPM) basis, as well as the aggregate annual cost to the plan.

Total Men at Risk for a Repeated Biopsy This budget impact analysis compares the proportion of the 2101 men in the cohort who are at risk for a repeated biopsy in 2 potential scenariosâ&#x20AC;&#x201D;the reference scenario and the new scenario, which is using the epigenetic assay. In the reference scenario, many patients with rising or elevated PSA levels will be seen again for DRE or PSA testing, and be considered for a repeated biopsy. In this standard of care, 43% (903) of the patients with a histopathologically negative biopsy are referred for a repeated biopsy based on persistent clinical risk factors.13 In the new scenario, these same patients are triaged with the epigenetic assay. In the new scenario, 3% of patients would not be eligible for the epigenetic assay, because of atypical small acinar proliferation (ASAP) found in their previous biopsy tissue.12 The model assumes that patients with ASAP will receive a repeated biopsy, given the high risk of prostate cancer associated with this histopathologic finding. Approximately 99.9% of all cases

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Vol 6, No 1

Epigenetic Assay: Screening for Prostate Cancer

would have sufficient tissue for this epigenetic assay, leaving 875 evaluable cases (based on 2 quality-not-sufficient cases of 749 in laboratory experience, through November 30, 2012, when the data were collected).

The Epigenetic Assay The multiplex DNA methylation epigenetic assay became available in the United States in May 2012 (through MDxHealthâ&#x20AC;&#x2122;s CLIA-accredited, CAP-certified laboratory in Irvine, CA). The performance characteristics of this assay (Table 1) were described in the MATLOC clinical trial, which investigated the clinical utility of this assay.8 These characteristics were used in our budget impact model to determine the anticipated number of patients who would be identified as positive or negative for methylation markers. The test is designed such that its high (90%) negative predictive value accurately distinguishes the patients with negative prostate biopsies from patients who may have occult cancer.8 In the budget impact model, under the reference scenario, 43% (903) of men at risk for repeated biopsy were referred for repeated biopsy. In the new scenario, testing the high-risk patients with the epigenetic assay significantly reduced the number of repeated biopsies by confirming the histopathologically negative biopsy results for 510 men. The epigenetic assay identified 365 men with positive DNA methylation results who would be referred for repeated biopsy (Table 2). Model Variables and Assumptions Conservative assumptions were made as to the number

Table 1 Diagnostic Accuracy of the Epigenetic Assay Variable

Rate

Initial biopsy false-negative rate

0.18

Multiplex DNA Methylation Epigenetic Assay Sensitivity

0.68

Specificity

0.64

Negative predictive value

0.90

Positive predictive value

0.29

Source: Reference 10.

of repeated biopsies based on reported rates. In the standard of care, 43% of men are referred to have 1 repeated biopsy, 44% of which have a second biopsy, and 43% of these have a third biopsy. The 100% of men tested with the epigenetic assay who are methylation-positive were assumed to receive a repeated biopsy. A total of 1472 repeated biopsies are expected to be performed in the reference scenario compared with only 365 repeated biopsies with the epigenetic assay in the new scenario. The average cost of a prostate biopsy procedure is $1946, which is a conservative estimate, based on decreased interim 2013 Medicare Physician Fee Schedule rates; this does not take into account prophylactic antibiotic, pain, or other concomitant medication costs.25 The total expected complication costs per patient for an initial or repeated biopsy were calculated using Surveillance,

Table 2 Men at Risk for a Repeated Prostate Cancer Biopsy Reference scenario (standard of care)

New scenario (epigenetic assay)

2101

Men referred for repeated biopsy or methylation test, %

Number of men referred for repeat biopsy or methylation test, N

903

N/A

99.9%

Evaluable cases, N

N/A

875

Cases with positive methylation markers, N

N/A

365

Cases with negative methylation markers, N

N/A

510

903

365

Variable Men at risk of repeated biopsy, N

Number of men with ASAP, % Cases with sufficient tissue for methylation test, % Risk stratification based on methylation markers

Total men referred for repeated biopsy, N ASAP indicates atypical small acinar proliferation; N/A, not applicable.

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Table 3 Per-Patient Costs Associated with Biopsy Complications DRG Incidence Perpayment, (SEER- patient $ Medicare) cost, $

Infectious complications Kidney infection

5594

Urinary tract infection

5594

Prostatitis

6220

Cystitis

5594

Sepsis/bacteremia

16,662

Endocarditis

10,943

Hypotension

5801

Average payment for infectious complications

8058

0.04

322

DRG Incidence Perpayment, (SEER- patient $ Medicare) cost, $

Noninfectious complications Gastrointestinal hemorrhage

6559

Hematuria

5366

Acute posthemorrhagic anemia

5660

Urinary symptoms/retention

5594

Average payment for noninfectious complications

5795

0.012

Total cost

392

DRG indicates diagnosis-related group; SEER, Surveillance, Epidemiology and End Results.

Table 4 Total Resource Use: Repeated Prostate Biopsies Reference New scenario scenario (standard (epigenetic of care) assay)

Resource Total men referred for first repeated biopsy, N

903

Total men referred for second repeated biopsy, N

397

Total men referred for third repeated biopsy, N

171

Total epigenetic tests, N

875

Total repeated biopsies, N

1472

365

903

Total repeated biopsies avoided, N

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1106

Epidemiology and End Results (SEER)-Medicare cancer registries’ reported incidence of infectious and noninfectious complications and the associated mean payment for the Medicare Severity-Diagnosis Related Groups (MSDRGs) from the 2012 Centers for Medicare & Medicaid Services MS-DRG payment schedule.22 Table 3 shows the calculations for the average cost ($392) of complications per patient undergoing repeated prostate cancer biopsy. The total weighted cost of a fully burdened biopsy is $1946—the sum of the procedural cost and the cost of complications weighted by incidence. The retail price for the epigenetic assay is $206 per individual core, or $2061 for a 10-core biopsy (pricing is based on the cost of the ConfirmMDx for Prostate Cancer Test, as provided by MDxHealth, the manufacturer of this test). The model assesses the health plan’s costs compared with billed charges; therefore, the cost of this assay is discounted by 10%, to conservatively reflect payer costs, at $1855.02 per test.

Results Costs This budget impact analysis demonstrates that the net cost to a commercial plan is lower if patients undergoing prostate cancer biopsies are managed using the assay. Although this involves an additional cost for the acquisition of the assay, using the assay results in a reduction of 1106 unnecessary biopsies for a health plan with 1 million members (Table 4). The total cost of repeated biopsies avoided is $2,152,276 (1106 biopsies avoided × $1946 per biopsy). The total cost to the health plan in 1 year was calculated to be $2,864,142 in the reference scenario versus $2,333,341 with the epigenetic assay in the new scenario. To calculate the total diagnostic cost per patient in the reference scenario, the cost of a prostate biopsy ($1946) was applied and weighted to a repeated biopsy distribution rate for the percentage of men who receive first, second, and third repeated biopsies of 43%, 44%, and 43%, respectively.13 For the new scenario, the total diagnostic cost per patient includes the cost of the assay plus the weighted biopsy cost, applied and weighted to 43% of men who have positive results based on the epigenetic assay (based on the sensitivity, specificity, and negative and positive predictive values).8 The total diagnostic cost per patient was $3172 in the reference scenario compared with $2584 in the new scenario, resulting in a savings of $588 per patient managed. This results in a total savings of $530,801 annually to the health plan, or –$0.0442 PMPM (Table 5). Sensitivity Analysis To test for uncertainty among the model parameters,

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Table 5 Total Annual Costs and Budget Impact: Reference Scenario versus New Scenario Reference scenario (standard of care)

New scenario (epigenetic assay)

Total annual cost, $

PMPM cost, $

Total annual cost, $

PMPM cost, $

Total cost of epigenetic assay

1,623,143

0.14

Total cost of repeated biopsies

2,864,142

0.33

710,198

0.06

2,152,276

0.18

2,864,142

0.24

2,333,341

0.19

3172

0.24

2584

0.19

Cost

Total cost of repeated biopsies avoided Total diagnostic cost to health plan Total diagnostic cost per patient Total budget impact to plan

–530,801

Total budget impact to plan PMPM

–0.442

PMPM indicates per member per month.

Table 6 Sensitivity Analysis: Total Costs and Budget Impact Reference scenario (standard of care)

New scenario (epigenetic assay)

Total annual cost, $

PMPM cost, $

Total annual cost, $

PMPM cost, $

Total cost of epigenetic assay

0.00

5,346,168

0.53

Total cost of repeated biopsies

9,429,097

1.09

2,342,681

0.27

0.00

7,086,416

0.82

9,429,097

1.09

7,688,849

0.81

3172

0.33

2584

0.24

Cost

Total cost of repeated biopsies avoided Total diagnostic cost to health plan Total diagnostic cost per patient Total budget impact to plan

–1,740,248

Total budget impact to plan PMPM

–0.1450

PMPM indicates per member per month.

all calculations were repeated for a patient population of men aged ≥65 years, representative of the Medicare population. Patients older than age 74 years were excluded from the model, resulting in an at-risk cohort of 6917 men. Testing these patients with the assay resulted in a reduction of 3642 unnecessary biopsies. The total cost of repeated biopsies avoided was $7,086,416. The total cost to the plan in 1 year was $9,429,097 in the reference scenario and $7,688,849 in the new scenario. This resulted in a total budget impact of –$1,740,248 to the plan, or –$0.1450 PMPM. The total diagnostic cost per patient was $3172 in the reference scenario compared with $2584 in the new scenario (Table 6), resulting in a savings of $588 per patient managed.

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Discussion The budget impact model was developed to evaluate the clinical and financial benefits of payer coverage for the epigenetic assay, also considering the clinical benefits, based on well-founded and conservative assumptions from existing evidence and current standards of care for patients considered at risk for prostate cancer. The analysis demonstrates that a commercial health plan would realize cost-savings with the coverage of the epigenetic assay. The upfront cost of the epigenetic assay will be recovered based on the savings associated with avoided biopsy procedures and associated complications of biopsies. Given these assumptions and the costs associated with the current standard of care, the inclusion of

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the epigenetic assay into the management of men who are screened for prostate cancer would result in a net cost-savings of â&#x20AC;&#x201C;$530,801 in the first year after the assay became available in the United States in a health plan with 1 million members.

Approximately $1.8 billion is spent annually on PSA testing alone, and more than $4 billion is spent on prostate cancer therapies, leading the AUA to call for new biomarkers to improve accurate diagnosis and reduce the cost burden. The epigenetic assay provides clear and actionable results that aid the urologist in treatment decision-making, improving patient care, and yielding significant healthcare savings. A key assumption is that a health plan inclusion of the epigenetic assay in medical policy and coverage decisions will motivate a change in the behavior of urologists, resulting in a reduction of repeated biopsies. Policy tools that promote appropriate patient management according to evidence-based guidelines, such as value-based payment (eg, financial incentives for choosing evidence-based interventions) or coverage restrictions for repeated biopsies, may further enhance such outcomes.

Limitations The results of this budget impact analysis are based on a hypothetical cohort modeled on the basis of values from the published literature. The use of national averages may not reflect the true variety in clinical practice. Initial prostate biopsy and repeated biopsy rates in specific geographic regions may be higher or lower than the reported national averages. Costs and resource utilization may also vary between practices and between geographic regions. Another potential limitation to the application of this model is that the future rates of screening for prostate cancer may vary, given the recent recommendation of the USPSTF to stop routine PSA-based prostate cancer screening.6 The recommendation suggests that physicians discuss the benefit-risk ratio with their patients and decide if PSA testing is appropriate based on risk factors such as race or family history.6 How this will affect screening rates is not yet known and is not explored in this analysis. This study is intended to address the financial impact of the epigenetic assay on the costs to commercial health plans of repeated biopsies. Because the cost impact is associated with a reduction in complications from the

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biopsy, the study provides some perspective on the impact of the assay on clinical outcomes. However, clinical outcomes were not evaluated in the design of the present study. A cost-effectiveness analysis would be the suitable approach to investigate the cost and the clinical outcomes associated with the use of the assay. In addition, the assayâ&#x20AC;&#x2122;s impact on the rates of prostate cancer diagnosis and earlier case identification were outside the scope of the study and were not methodically investigated. Subgroup analyses were not performed for modestly elevated PSA patients versus those with markedly elevated PSA, because these patients are not managed differently in clinical practice. Because of the negative predictive value of 90% of the epigenetic assay, 10% of patients testing negative with the assay could have a diagnosis of prostate cancer identified through recommended return screening. The clinical impact of this is not evaluated by the design of this model. The test has only been commercially available in the United States since May 2012.

Conclusion Approximately $1.8 billion is spent annually on PSA testing alone, and more than $4 billion is spent on prostate cancer therapies, leading the AUA to call for new biomarkers to improve accurate diagnosis and reduce the cost burden. Epigenetic assays have been reported to improve the accuracy of prostate biopsies and help to prevent repeated biopsies, the majority of which show negative results. Based on a recent analysis, the results of a new epigenetic assay can guide urologists in decisions regarding the need to repeat a biopsy in patients with a previously negative biopsy who are still considered at risk for prostate cancer. A budget impact analysis calculated whether this assay can also produce financial benefits, beyond the previously reported clinical benefits. Using a hypothetical health plan with 1 million members, this analysis shows that the total annual cost to the health plan would be reduced if patients with histopathologically negative biopsies would be managed with the epigenetic assay. Specifically, the use of the assay would reduce the number of repeated biopsies from 1472 to 365, thereby preventing 1106 unnecessary biopsies and reducing the annual costs by approximately $500,000 to the health plan, based on the current standard of care. This test has only been available for a short time. Research to investigate the clinical impact of this essay based on real-world data will be appropriate. Disclaimer At the time this study was submitted for publication,

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prostate biopsy costs incorporated maximum payment reductions; conversion factor $25.0008 per the 2013 Medicare Physician Fee Schedule published December 5, 2012. If changes to the sustainable growth rate patch and sequestration cuts occur, savings for payers reimbursing the epigenetic assay may be greater than reported. n Author Disclosure Statement Dr Aubry is a Consultant to MDxHealth. Dr Lieberthal receives research/grant support from Abbott Molecular, Genomic Health, and MDxHealth. Dr A. Willis is a Consultant to ConfirmMDx and 21st Century Oncology, and is on the Speaker’s Bureau for Astellas, Clinlogix, GlaxoSmithKline, Eli Lilly, and sanofi aventis. Dr Bagley is a Consultant/Advisor to HillCo Health. Mr Layton is a Consultant to ConfirmMDx. Mr S.M. Willis has nothing to disclose.

References

1. Loeb S, Carter HB, Berndt SI, et al. Complications after prostate biopsy: data from SEER-Medicare. J Urol. 2011;186:1830-1834. Epub 2011 Sep 23. 2. Ekwueme DU, Stroud LA, Chen Y. Cost analysis of screening for, diagnosing, and staging prostate cancer based on a systematic review of published studies. Prev Chronic Dis. 2007;4:A100. 3. Van Neste L, Herman JG, Otto G, et al. The epigenetic promise for prostate cancer diagnosis. Prostate. 2012;72:1248-1261. 4. Mosquera J-M, Mehra R, Regan MM, et al. Prevalence of TMPRSS2-ERG fusion prostate cancer among men undergoing prostate biopsy in the United States. Clin Cancer Res. 2009;15:4706-4711. 5. National Cancer Institute. Surveillance, Epidemiology and End Results. 2012. http://seer.cancer.gov/csr/1975_2009_pops09/results_single/sect_01_table.01.pdf. Accessed November 1, 2012. 6. US Preventive Services Task Force. Screening for Prostate Cancer. May 2012. www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm. Accessed September 20, 2012. 7. Crawford D, Grubb R, Pinsky P, Black A. Factors influencing initial treatment decisions in PLCO: comparison of screening and control arms. Abstract LBA4. Proceedings of the AUA Annual Meeting, May 21, 2012; Atlanta, GA. 8. Stewart G, Van Neste L, Delvenne P, et al. Clinical utility of a multiplexed epi-

genetic gene assay to detect cancer in histopathologically negative prostate biopsies: results of the multicenter MATLOC study. J Urol. (2012), doi: 10.1016/j.juro.2012. 08.219. 9. Kehinde EO, Al-Maghrebi M, Sheikh M, Anim JT. Combined ciprofloxacin and amikacin prophylaxis in the prevention of septicemia after transrectal ultrasound-guided biopsy of the prostate. J Uro. 2012 September 23. pii: S0022-5347(12) 04945-2. doi: 10.1016/j.juro.2012.08.237. 10. Trock B, Brotzman MJ, Mangold LA, et al. Evaluation of GSTP1 and APC methylation as indicators for repeat biopsy in a high-risk cohort of men with negative initial prostate biopsies. BJU Int. 2012;110:56-62. 11. Rabets JC, Jones JS, Patel A, Zippe CD. Prostate cancer detection with office based saturation biopsy in a repeat biopsy population. J Urol. 2004;172:94-97. 12. Laurila M, van der Kwast T, Bubendorf L, et al. Detection rates of cancer, high grade PIN and atypical lesions suspicious for cancer in the European Randomized Study of Screening for Prostate Cancer. Eur J Cancer. 2010;46:3068-3072. 13. Pinsky PF, Crawford ED, Kramer BS, et al. Repeat prostate biopsy in the prostate, lung, colorectal and ovarian cancer screening trial. BJU Int. 2007;4:775-779. 14. Resnick MJ, Lee DJ, Magerfleisch L, et al. Repeat prostate biopsy and the incremental risk of clinically insignificant prostate cancer. Urology. 2011;77:548-552. 15. National Cancer Institute Trends Progress Report-2009/2010 Updated. www.cancer. gov/newscenter/newsfromnci/2010/ProgressReport2010. Accessed November 1, 2012. 16. Merril J. Prostate cancer market snapshot: more than provenge. The Pink Sheet. November 22, 2010. Elsevier Business Intelligence Publications and Products. www. elsevierbi.com/Publications/The-Pink-Sheet/72/47/Prostate-Cancer-MarketSnapshot-More-Than-Provenge?result=2&total=2&searchquery=%253fq%253dPros tate%252520Cancer%252520Market%252520Snapshot%2526date%253don%252 53a11%25252f22%25252f2010. Accessed January 29, 2013. 17. Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol. 2007;177:2106-2131. 18. Stricker S. The era of personalized medicine in oncology: novel biomarkers ushering in new approaches to cancer therapy. Am Health Drug Benefits. 2011;4:387-388. 19. Mehrotra J, Varde S, Wang H, et al. A quantitative, spatial resolution of the epigenetic field effect in prostate cancer. Prostate. 2008;68:152-160. 20. Trujillo KA, Jones AC, Griffith JK, Bisoffi M. Markers of field cancerization: proposed clinical applications in prostate biopsies. Prostate Cancer. 2012;2012:302894. 21. Centers for Medicare & Medicaid Services. Medicare Physician Fee Schedule 2013. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Physician FeeSched/ index.html?redirect=/physicianfeesched/. Accessed December 5, 2012. 22. Centers for Medicare & Medicaid Services. Medicare Inpatient Prospective Payment System 2012. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ AcuteInpatientPPS/index.html. Accessed December 5, 2012. 23. US Census Bureau. Age and sex composition: 2010. 2010 census briefs. www. census.gov/prod/cen2010/briefs/c2010br-03.pdf. Accessed November 1, 2012. 24. Drazer MW, Huo D, Schonberg MA, et al. Population-based patterns and predictors of prostate-specific antigen screening among older men in the United States. J Clin Oncol. 2011;29:1736-1743. Epub 2011 Mar 28. 25. Nichol MB, Wu J, An JJ, et al. Budget impact analysis of a new prostate cancer risk index for prostate cancer detection. Prostate Cancer Prostatic Dis. 2011;14:253-261.

Stakeholder Perspective

Molecular Epigenetic Tests Can Improve Clinical Outcomes While Reducing Healthcare Costs By Kelly Huang, PhD President, HealthTronics, Inc, Austin, TX

HEALTH PLANS: Health insurance plans and other payers recognize the potential for molecular diagnostics to facilitate the approach known as personalized medicine, which utilizes molecular testing to identify patients who will benefit from a specific approach to management or a specific targeted therapy. Personalized medicine can lead to reduced healthcare costs over the life of the patient. However, payers are struggling to keep up with the rapidly expanding range of molecular tests. Because of the ambiguous nature of “laboratory-devel-

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oped tests,” many health insurers are deeming many new tests as experimental or investigational and are therefore refusing to cover them. When determining coverage of molecular diagnostic tests, payers expect evidence not only for clinical utility but also for cost-effectiveness.1 It follows that cost-effectiveness should also lead to a reimbursement structure that is based on the value of that test or service rather than merely on stacking codes of the methodology steps. In this current article by Aubry and colleagues, the Continued

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Stakeholder Perspective Continued authors propose a well-articulated hypothetical model to assess the value of an epigenetic test’s (ConfirmMDx) ability to confirm the negative results of a prostate biopsy. According to this model, using this test leads to a meaningful $588 savings per patient managed, by avoiding unnecessary repeated prostate biopsies. As with any hypothetical model, there are limitations to the analysis with regard to real-world facts. Nev ertheless, the authors clearly outline their assumptions and the rationale behind their calculations, so that readers can consider the conclusions, assess the sensitivity of the assumptions, and arrive at their own perspective. Beyond the economic benefits of this test, payers should also consider the improvement in quality of life for patients who avoid the need for repeated biopsies. PATIENTS/PROVIDERS: Patients and providers will experience the benefits of many new and soon-tobecome-available advances in the detection and treatment of prostate cancer. Along with new drug therapies and surgical advances, such as minimally invasive abla-

tive procedures, molecular epigenetic tests show promise in determining the aggressive nature of a tumor, or in the case of ConfirmMDx, provide true confirmation of negative biopsy results. Although these epigenetic tests are relatively new, they already provide further input, along with the details of the biopsy results, prostate-specific antigen history, family history, digital rectal examination, age, and so on, to help the physician’s and the patient’s determination of a specific treatment regimen. Over time, as more experience is gained and the tests are improved for specificity and sensitivity, molecular epigenetic tests can be expected to provide significant improvements in extended survival and enhanced quality of life for patients. n 1. Trogan G. What do payers want in oncology diagnostics? Insights from a national survey of top commercial and Medicare health plans. Am Health Drug Benefits. 2011; 4 (4 Special Issue):34.

Disclosure: HealthTronics offers Laboratory Solutions, including ConfirmMDx and other epigenetic testing for prostate cancer.

Information for Authors Manuscripts submitted to American Health & Drug Benefits (AHDB) must be original and must not have been published previously, either in print or in electronic form. Manuscripts cannot be submitted elsewhere while under consideration by AHDB, and must adhere to the format described in the full Guidelines for Authors available at www.AHDBonline.com. All manuscripts undergo peer review, and acceptance is based on that review. If accepted, authors will be notified of any recommended revisions. Routine editorial changes are made to conform to house style, following the AMA Manual of Style, 10th ed. (New York, NY: Oxford University Press, 2007). Time from submission to publication is generally 3 to 5 months. COPYRIGHT/DISCLOSURE

Authors must sign a Copyright Transfer Form, assigning all copyrights to Engage Healthcare Communications, LLC, publisher of AHDB, as well as a Financial Disclosure Form, disclosing any financial interests or potential conflict of interest involving the materials discussed in the manuscript. MANUSCRIPT FORMAT

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Industry Trends

As Deadline Nears, Health Insurance Exchanges Making Progress, with Some Setbacks By Dalia Buffery, MA, ABD Editorial Director, American Health & Drug Benefits

n December 12, 2012, Secretary of Health and Human Services (HHS) Kathleen Sebelius mused in her blog on the progress made by health plans toward the establishment of the health insurance exchanges, which will open the world of health insurance to many currently uninsured, as well as insured, Americans. States can choose to establish their own exchange, enter into a state-federal partnership, or default to an exchange that will be set up and run by the federal government, under the auspices of the HHS Secretary.

The Progress “Ten months from today, Americans in every state can begin to choose health insurance in new state marketplaces where they will have access to affordable care. Many will have never had health insurance, or had been forced to make the decision to go without insurance after losing a job or becoming sick,”1 HHS Secretary Sebelius wrote in December. “Today, we’re announcing that six states who applied early have made enough progress setting up their own marketplaces or Exchanges that we are ready to conditionally approve their plans—meaning they are on track to meet all Exchanges deadlines. These…states include: Colorado, Connecticut, Mas sachusetts, Maryland, Oregon, and Washington.”1 That was 2 months ago. Now, early in February 2013, a total of 18 states (including the District of Columbia) have received conditional approval to establish a state exchange, and 7 are planning state-federal partnership exchanges; the balance of 26 states will default to the federal exchange, unless they manage to submit a plan by the imminent deadline.2 The deadline to submit a plan for a state or a state-federal partnership exchange is February 15, 2013, with open enrollment starting on October 1, 2013, and coverage beginning on January 1, 2014. The 12 states that have joined the original 6 states in planning to establish a state exchange are California, Connecticut, Hawaii, Idaho, Kentucky, Minnesota, New Mexico, New York, Rhode Island, Utah, Vermont, and Washington, DC.2

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Why Establish an Exchange? Why establish a health insurance exchange? Despite the considerable efforts and logistics involved in fulfilling the demands required to establish an exchange, it is generally accepted that health plans are poised to benefit financially from participation in the exchanges, with approximately 29 million to 30 million uninsured Americans anticipated to buy health insurance through these exchanges, to the tune of $205 billion by 2021, according to one analysis.3 Last year, WellPoint, one of the largest health plans in the country, reportedly allotted at least $50 million to enhance its “brand” in preparation for the exchanges, and it is expected to spend as much this year.4 The explanation for such spending by one of the best-recognized health insurance companies, according to WellPoint, is that the company “expects the future purchase of health insurance to function more like online retailing than even before, where brand name, along with price and convenience, win the day.”4 WellPoint’s Chief Financial Officer Wayne DeVeydt explained it this way last year, “As you think about 2014, you’re going to have to market in a more retail environment, something that this industry hasn’t had to do historically, and branding is going to become more relevant.”4

WellPoint’s Chief Financial Officer Wayne DeVeydt explained it this way last year, “As you think about 2014, you’re going to have to market in a more retail environment, something that this industry hasn’t had to do historically, and branding is going to become more relevant.” If WellPoint’s predictions materialize, the exchanges may inherently change the face of health insurance into something new. Only time will tell. However, even

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with the potential for considerable financial gains for health plans and gain of access for patients, the logistics of establishing the exchanges on such a large scale present challenges for all stakeholders.

The Setbacks There is no doubt that such a large undertaking is more complex than might have first appeared even to those who wrote the law. On January 24, 2013, federal regulators have announced the delay of one of the Affordable Care Act (ACA)’s requirements—that employers notify their employees by March 1, 2013, about the availability of health insurance exchanges that are to be open to people insured in their state. The expectation now is that employees will be given notifications by their employers sometime during the summer, just in time for the October 1 open enrollment date.5 The reason cited for the delay was the need to give employers more time to appropriately coordinate with the exchanges.

On February 8, 2013, Mississippi became the first state to have its health exchange plan rejected by the HHS, citing Governor Phil Bryant’s opposition to the health insurance exchange plan as the reason for this development. Nevertheless, the HHS and other federal regulators are confident that the deadlines will be met. “We are committed to a smooth implementation process, including providing employers with sufficient time to comply and selecting an applicability date that ensures that employees receive the information at a meaningful time,” they said.5 On February 8, 2013, Mississippi became the first state to have its health exchange plan rejected by the HHS, citing Governor Phil Bryant’s opposition to the health insurance exchange plan as the reason for this development. “With a lack of support from your governor and no formal commitment to coordinate from

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other state agencies, we do not see a feasible pathway to conditionally approving a state-based exchange in Mississippi for 2014,” the HHS wrote in a letter to the state of Mississippi.6 Politics may indeed be the reason for this development. “Mississippi Insurance Commissioner Mike Chaney, a Republican, had waged a bitter battle with [Governor Phil] Bryant and other fellow party leaders in his state over implementing a state-run health insurance exchange,”6 which is being seen as an issue that promotes the Democratic Party and the president’s healthcare reform platform. Governor Bryant opposes the idea of a state-based health insurance exchange, which he sees as an act of embracing the ACA, believing that it “will shackle the state with debt related to inflated Medicaid rolls.”6 The HHS Secretary said that she considered Mississippi “an excellent candidate” for a state-federal partnership exchange.6 n

Moving Forward As we move closer to the various time points in the road toward establishing the exchanges, more progress and some setbacks can be expected, but for now at least, the majority of the states are moving forward, in one fashion or another, with plans in place to address the ACA’s requirement of health insurance exchanges. The potential for billions of dollars in saving for health plans can only mean good things for members and patients. References

1. Sebelius K. Progress continues in setting up health insurance marketplaces. HealthCare.gov. December 12, 2012. www.healthcare.gov/blog/2012/12/market places121012.html. Accessed February 3, 2013. 2. Kaiser Family Foundation. States decisions for creating health insurance exchanges in 2014. February 8, 2013. www.statehealthfacts.org/comparemaptable.jsp?ind=962 &cat=17. Accessed February 8, 2013. 3. PwC Health Research Institute. Health insurance exchange: long on options, short on time. October 2012. http://healthreformgps.org/wp-content/uploads/pwc-healthinsurance-exchanges-impact-and-options.pdf. Accessed February 3, 2013. 4. Indianapolis Business Journal. WellPoint spends $50M to burnish brand. Septem ber 17, 2013. www.ibj.com/article/print?articleId=36730. Accessed February 3, 2013. 5. Jerry Geisel. Health insurance exchange reporting delayed. BusinessInsurance. com. January 25, 2013. www.businessinsurance.com/article/20130125/NEWS03/130 129877?tags=|62|63|307|329|74|278. Accessed February 3, 2013. 6. Le Coz E. US rejects Mississippi health insurance exchange plan. Reuters. February 8, 2013. http://news.yahoo.com/u-rejects-mississippi-health-insuranceexchange-plan-202610533.html. Accessed February 8, 2013.

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Call for Papers Cardiometabolic Health Special Issue American Health & Drug Benefits will be publishing a Special Issue on Cardiometabolic Health in 2013

Readers are invited to submit articles for publication in this special issue on topics relevant to the clinical, business, and policy aspects of cardiometabolic health and wellness. Original research, comparative effectiveness analyses, white papers, evidence-based comprehensive reviews, and case studies are of particular interest. All articles will undergo the journal’s rigorous peer-review process and acceptance is contingent on that review.

Topics of high interest include: • Insulin resistance and type 2 diabetes

• Benefit designs to improve cardiometabolic patient outcomes • Best practices in insulin control, lipid management, or blood pressure control • Comparative effectiveness analyses of best therapies for cardiovascular health • Cost-effectiveness comparisons of current therapies for diabetes • Current recommendations for optimizing A1C target outcomes • Diabetes management and prevention • Employers’ strategies to enhance employees’ cardiometabolic wellness • Emerging therapies for diabetes, heart disease, and/or obesity • Health plan initiatives for cardiometabolic health and prevention • Hot topics in diabetes management

• Lifestyle strategies and cardiometabolic health and wellness • Lipid management in patients with diabetes • Medication adherence • New biomarkers for assessing cardiometabolic risk • New therapies for diabetes, cardiovascular disease, or obesity • Optimal therapies for cardiovascular disease, diabetes, and/or obesity • Pharmacoeconomic analyses • Prevention strategies for diabetes risk reduction • Wellness programs for patients with heart disease, diabetes, or obesity

Articles must follow the Manuscript Instructions for Authors at www.AHDBonline.com. Submit articles to editorial@engagehc.com. For more information, call 732-992-1889.

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AN 8-PART SERIES

Value-BasedCare IN MULTIPLE MYELOMA

â&#x201E;˘

The therapeutic paradigm for multiple myeloma continues to evolve at a rapid pace. The goal of this newsletter series, published by the Association for Value-Based Cancer CareTM, is to provide our readers with recent clinical advances in myeloma treatment, as well as stakeholder perspectives on how emerging data can be used to promote high-quality, cost-effective care. Each supplement will explore a specific topic to be considered when developing value-based strategies. IN MULTIPLE MYELOMA

Value-BasedCare FEBRUARY 2013

Â&#x2122;

1st IN A SERIES

Treating Newly Diagnosed Multiple Myeloma: Data on Safety, EfďŹ cacy, and Dosing Regimens

Topics to include: Safety and Efficacy of Front-Line Treatment Assessing the Value of Complete Response Pharmacoeconomic Analysis of Treatment Options Therapeutic Decision Making Based on Cytogenetics Assessing the Value of Progression-Free Survival Data Safety and Efficacy of Therapies in the Relapsed Setting Using Alternate Routes of Drug Administration Cost-Effective Use of Imaging Techniques

Introduction The therapeutic paradigm for multiple myeloma (MM) continues to evolve, due to advances in our understanding of the molecular and genetic basis of the disease.1 Newly diagnosed patients typically undergo multidrug therapy that includes novel, targeted agents, often followed by consolidation with autologous stem cell transplantation (ASCT) and maintenance therapy.1,2 This therapeutic model has altered the value equation in newly diagnosed MM, because survival and life quality have increased along with cost of treatment.1 Enhanced survival, through the use of novel therapies, requires us to balance both short- and long-term outcomes. Over its clinical course, MM has one of the highest direct costs of any cancer.1 For example, in a 2007 analysis, the direct costs associated with a course of treatment with a novel agent plus a steroid (taking into account the drugs themselves, as well as prophylaxis and management of toxicities) ranged from approximately $47,000 to $72,000.1,3 Simple assessment of cost, however, is not sufďŹ cient, because value comprises not only expenses but also outcome over the increasingly prolonged survival time for MM. For example, in the VISTA trial (N=682), newly diagnosed, transplant-ineligible patients who were randomized to either triple therapy with bortezomib/melphalan/prednisone (VMP) or double therapy with melphalan/prednisone (MP) were followed for life quality over nine 6-week cycles.4 The study found that, through cycle 4, health-related quality of life (HRQoL) was lower with VMP than with MP, due to decreased treatment tolerability. However, from cycle 5 through the end of therapy, HRQoL with VMP was not compromised relative to MP, and recovered to the point where HRQoL was comparable for the 2 treatments.4 This investigation also demonstrated the link between antimyeloma efďŹ cacy and HRQoL. Among responders to therapy, HRQoL increased from the time of response to the end of treatment.4 Responders were more common in the VMP group than in the MP group in this trial, in which response rates were 71% and 35%, respectively (P<.001).5 In addition, 5-year overall survival (OS) was prolonged with VMP versus MP,6 another beneďŹ t to consider in the value equation. Pharmacoeconomic analysis of initial treatment with melphalan/prednisone/lenalidomide (MPR) followed by lenalidomide maintenance (MPR-R) reported that this regimen, although more expensive than MPR or MP without maintenance, yielded greater cost-effectiveness.7 Although MPR-R increased progression-free survival (PFS) compared with regimens without maintenance, no This newsletter has been supported by funding from Millennium: The Takeda Oncology Company

beneďŹ t in OS has yet been reported with MPR-R, so the observation of cost-effectiveness remains provisional.7 In todayâ&#x20AC;&#x2122;s healthcare environment, when evidence changes the value equation, it changes practice. Therefore, it is critical to be aware of current and emerging data on the tolerability and efďŹ cacy of novel agents, which will inďŹ&#x201A;uence therapeutic strategies. Tolerability: The Role of Optimized Dosing and Novel Drugs For newly diagnosed MM, current recommendations for care typically include the use of bortezomib, lenalidomide, or thalidomide in multidrug regimens, either for pre-ASCT induction or, in transplant-ineligible patients, as an initial course of therapy.2 All

OVERVIEW The therapeutic paradigm for multiple myeloma (MM) continues to evolve at a rapid pace. The goal of this newsletter series, published by the Association for Value-Based Cancer Care , is to provide our readers with recent clinical advances in myeloma treatment, as well as stakeholder perspectives on how emerging data can be used to promote high-quality, cost-ef topic to be considered when developing value-based newly diagnosed MM.

STAKEHOLDERSâ&#x20AC;&#x2122; PERSPECTIVES Assessing the Value of Novel Therapies for Multiple Myeloma ............................................. 5 By William J. Cardarelli, PharmD Atrius Health, Harvard Vanguard Medical Associates

Clinical and Economic Challenges in the Treatment of Multiple Myeloma........................ 6 By Kevin B. Knopf MD, MPH California PaciďŹ c Medical Center

An ofďŹ cial publication of

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THIRD ANNUAL

Association for Value-Based Cancer Care Conference Influencing the Patient-Impact Factor

This activity is jointly sponsored by the Florida Society of Clinical Oncology, Medical Learning Institute Inc, Association for Value-Based Cancer Care, Inc., Center of Excellence Media, LLC, and Core Principle Solutions, LLC.

May 2-5, 2013 • Westin Diplomat • Hollywood, Florida CONFERENCE CO-CHAIRS

AGENDA* THURSDAY, MAY 2, 2013 8:00 am - 5:00 pm

Registration

FRIDAY, MAY 3, 2013

Craig K. Deligdish, MD Hematologist/Oncologist Oncology Resource Networks

Gary M. Owens, MD President Gary Owens Associates

Burt Zweigenhaft, BS President and CEO OncoMed

7:00 am - 8:00 am

Simultaneous Symposia/Product Theaters

8:15 am - 9:15 am

Session 1: Welcome, Introductions, and Opening Remarks Conference Co-Chairs - Craig K. Deligdish, MD; Gary M. Owens, MD; Burt Zweigenhaft, BS

9:15 am - 10:15 am

Keynote Address

10:15 am - 10:30 am

Break

10:30 am - 11:45 am

Session 2: Trends in Treatment Decision-Making: Pathways and Stakeholder Collaborations Marcus Neubauer, MD; Michael Kolodziej, MD

12:00 pm - 1:00 pm

Exclusive Lunch Symposium/Product Theater

1:15 pm - 2:00 pm

Session 3: Cost of Cure: When, How, and How Much? John Fox, MD; John Hennessy

2:00 pm - 2:45 pm

Session 4: Where Is Oncology Care Headed in the Future? Jayson Slotnick, JD, MPH (Moderator); Barbara L. McAneny, MD

Upon completion of this activity, the participant will be able to: • Discuss the current trends and challenges facing all stakeholders in optimizing value in cancer care delivery. • Define the barriers associated with cost, quality, and access as they relate to healthcare reform and what solutions are currently being considered. • Compare and contrast the different approaches/tools providers and payers are utilizing to manage and deliver care collaboratively. • Examine the current trends in personalized care and companion diagnostics. • Analyze the patient issues around cost, quality, and access to care.

2:45 pm - 3:30 pm

Session 5: What Will the Cancer Delivery System Look Like in 2015? Ted Okon; John D. Sprandio, MD

TARGET AUDIENCE

PROGRAM OVERVIEW

Following on the success of our Second Annual Conference, AVBCC will be coming to Hollywood, Florida, on May 2-5, 2013. We continue to be guided by the expertise of leaders in these fields providing attendees with a thorough understanding of the evolution of the value equation as it relates to cancer therapies. Our goal is to be able to assist them in implementing, improving, and sustaining their organizations and institutions, while improving access for patients and ultimately quality patient care.

LEARNING OBJECTIVES

3:30 pm - 3:45 pm

Break

3:45 pm - 4:30 pm

Session 6: Employers and Oncology Care F. Randy Vogenberg, PhD, RPh (Moderator); Bridget Eber, PharmD; Patricia Goldsmith; Darin Hinderman

4:30 pm - 5:15 pm

Session 7: Advanced Care Directives: Palliative Care, Hospice, Ethics J. Russell Hoverman, MD, PhD; Thomas Smith, MD, FACP, FASCO

5:15 pm - 5:45 pm

Summary/Wrap-Up of Day 1

This conference is intended for medical oncologists, practice managers/administrators, and managed care professionals. Stakeholders in a position to impact cancer patient care, such as advanced practice nurses, pharmacists, and medical directors, are also invited to join this exciting forum.

6:00 pm - 8:00 pm

Cocktail Reception in the Exhibit Hall

DESIGNATION OF CREDIT STATEMENTS

8:15 am - 8:30 am

Opening Remarks

8:30 am - 9:15 am

Session 8: The Role of Government in the Future of Oncology Care Jayson Slotnick, JD, MPH

9:15 am - 10:00 am

Session 9: Medicaid: A Healthcare Delivery System Review Matthew Brow

10:00 am - 10:15 am

Break

10:15 am - 11:00 am

Session 10: Payer, Government, and Industry Insights: Balancing Cost and Quality Kip Piper

11:00 am - 11:45 am

Session 11: National Coalition for Cancer Survivorship: Medication Nonadherence Issues Pat McKercher; Lillie Shockney, RN, BS, MAS

SPONSORS

COMMERCIAL SUPPORT ACKNOWLEDGMENT

Grant requests are currently being reviewed by numerous supporters. Support will be acknowledged prior to the start of the educational activities.

SATURDAY, MAY 4, 2013 7:00 am - 8:00 am

PHYSICIAN CREDIT DESIGNATION

The Medical Learning Institute Inc designates this live activity for a maximum of 17.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Medical Learning Institute Inc and the Center of Excellence Media, LLC. The Medical Learning Institute Inc is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

REGISTERED NURSE DESIGNATION

Simultaneous Symposia/Product Theaters

12:00 pm - 1:00 pm

Exclusive Lunch Symposium/Product Theater

1:15 pm - 3:00 pm

Session 12: Meet the Experts Networking Roundtable Session

3:00 pm - 3:45 pm

Session 13: Personalized Medicine, Companion Diagnostics, Molecular Profiling, Genome Sequencing—The Impact on Cost, Treatment, and the Value Proposition Mark S. Boguski, MD, PhD; Gary Palmer, MD, JD, MBA, MPH

3:45 pm - 4:15 pm

Summary/Wrap-Up of Day 2

4:30 pm - 6:30 pm

Cocktail Reception in the Exhibit Hall

Medical Learning Institute Inc. Provider approved by the California Board of Registered Nursing, Provider Number 15106, for 17.25 contact hours.

SUNDAY, MAY 5, 2013

REGISTERED PHARMACY DESIGNATION

8:15 am - 8:30 am

Opening Remarks

8:30 am - 9:15 am

Session 14: Cancer Rehabilitation: The Next Frontier in Survivorship Care Julie Silver, MD

9:15 am - 10:00 am

Session 15: Current and Future Considerations for the Oncology Practice Manager Dawn Holcombe, MBA, FACMPE, ACHE; Leonard Natelson

The Medical Learning Institute Inc is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Completion of this knowledge-based activity provides for 17.25 contact hours (1.725 CEUs) of continuing pharmacy education credit. The Universal Activity Number for this activity is (To be determined).

CONFERENCE $375.00 until March 15, 2013 REGISTRATION $425.00 after March 15, 2013 REGISTER TODAY AT

www.regonline.com/avbcc2013

7:00 am - 8:00 am

Simultaneous Symposia/Product Theaters

10:00 am - 10:15 am

Break

10:15 am - 11:00 am

Session 16: Access to Drugs—Shortages, Biosimilars Douglas Burgoyne, PharmD; James T. Kenney, Jr., RPh, MBA

11:00 am - 11:45 am

Session 17: Perspectives from Oncology Group Practices—Successes, Issues, and Challenges Thomas Marsland, MD; David Eagle, MD

11:45 am - 12:00 pm

Summary and Conclusion of Conference

*Agenda is subject to change. AVBCCAsize20413

business business

Review Article

The Opportunity for Health Plans to Improve Quality and Reduce Costs by Embracing Primary Care Medical Homes Sarah Collins, MBA; Kevin B. “Kip” Piper, MA, FACHE; Gary Owens, MD

Stakeholder Perspective, page 38

Am Health Drug Benefits. 2013;6(1):30-38 www.AHDBonline.com Disclosures are at end of text

Background: The large and growing costs of healthcare will continue to burden all payers in the nation’s healthcare system—not only the states that are struggling to meet Medicaid costs and the federal government, but also the private health plans that serve commercial, Medicare Advantage, and Medicaid beneficiaries. Cost will increasingly become a concern as millions more people become newly insured as a result of the Patient Protection and Affordable Care Act (ACA). Primary care delivery through patient-centered medical homes (PCMHs) and other coordinated-care models have improved care and reduced costs. Health plans have a strategic opportunity to promote better care at a lower cost by embracing medical homes and encouraging their growth. Health plans can play an important role in transforming the US healthcare system, as well as better position themselves for long-term corporate success. Objectives: To discuss several examples of organizations that serve a variety of beneficiaries and have been successful in promoting medical homes and coordinated primary care, and to suggest steps that health plans can take to improve the quality of care and reduce costs. Discussion: The models discussed in this article take a number of different approaches to create incentives for high-quality, cost-effective, coordinated primary care. Several health plans and groups use enhanced fee-for-service or per-member per-month payment models for primary care physician (PCP) practices that reach a specified level of medical home or electronic health record certification. Most of the examples addressed in this article also include an additional payment to encourage care management and coordination. The results showed a significant decline in costs and in the use of expensive medical services. One Medicaid coordinated-care program we reviewed saved almost $1 billion in reduced spending over 4 years, and achieves savings of approximately 15% within 6 months of the beneficiaries’ enrollment into their program. Another PCMH payer program led to an approximate 28% reduction in acute care hospital admissions among Medicare beneficiaries and an approximate 38% reduction in admissions among commercial beneficiaries. Conclusion: Based on the review of real-world examples, we recommend 6 steps that health plans can use to take advantage of the opportunity to embrace medical homes as a means to improve healthcare quality and to reduce costs. These recommendations include getting feedback from PCPs to improve plan provider networks, creating value-based primary care reimbursement systems, encouraging biannual visits with high-risk patients, funding case managers for high-risk patients, considering Medicaid coordinated-care models, and promoting ACA policies that support primary care.

he large and growing cost of healthcare, which amounted to 17.9% of the gross domestic product in 2011,1 will continue to be a burden for all payers in

Ms Collins is President, America’s Health, Oak Hill, VA; Mr Piper is President, Health Results Group, Washington, DC; and Dr Owens is President, Gary Owens and Associates, Glen Mills, PA.

American Health & Drug Benefits

the US healthcare system, not only for states that are struggling to meet Medicaid costs and the federal government’s requirements, but also for private health plans that serve commercial, Medicare Advantage, and Medicaid beneficiaries.2,3 Costs will continue to grow as millions more people become newly insured because of the Patient Protection and Affordable Care Act (ACA). Primary care that is delivered through patient-centered

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medical homes (PCMHs) and other coordinated- care models has served as a means to improve care and to reduce costs.4,5 Health plans, therefore, have a strategic opportunity to promote better care at a lower cost by embracing medical homes and encouraging their growth. Using this strategy would enable health plans to play an impor tant role in transforming the US healthcare system, and to be better positioned for long-term corporate success. Large business groups already have taken note of the potential for primary care and medical homes to reduce their healthcare costs. The National Business Group on Health (NBGH), which has more than 300 large corporate members that provide health insurance for 50 million Americans, has made primary care, and more recently the PCMH model, a priority “for years,” said NBGH Vice President Veronica Goff in an April 18, 2012, telephone interview. Several large employers are conducting PCMH pilot programs, including IBM, Boeing, Whirlpool, Dow Chemical, and Perdue Farms. Some state Medicaid programs and private health plans have also launched efforts to establish medical homes. In this article, we discuss several examples of organizations that serve a variety of beneficiaries and that have been successful in promoting medical homes and coordinated primary care. We review their results and make recommendations to health plans that are interested in seizing this opportunity.

Defining and Certifying Patient-Centered Medical Homes The PCMH model has been widely discussed in recent years. In 2007, the 4 major associations representing 333,000 primary care physicians (PCPs) issued joint principles of the PCMH model.6 These principles indicate that a PCMH should include6: • A personal physician • A team approach • A patient-centric focus • A dedication to quality and safety, including evidence- based medicine and clinical decision support tools • Coordinated care across settings • Enhanced access for patients, such as through open scheduling, e-mail, and expanded hours • Appropriate, enhanced payment. In 2008, the National Committee for Quality Assurance (NCQA) released its first set of standards and guidelines for PCMH recognition, which were revised and reissued in 2011.7 Practices that were recognized under the 2008 NCQA guidelines have 3 years from the date of recognition to update their practices to match the 2011 guidelines. “As of January 2013, 5198 sites with a total of 24,544 clinicians had received NCQA recognition,” said Peggy

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Key Points As more Americans become insured under the ACA, healthcare costs will increase in our already burdened healthcare system. ➤ Primary care medical homes, especially PCMHs, have been shown to improve the quality of care for patients and reduce costs by delivering high-quality, cost-effective, coordinated care. ➤ Typically, health plans and provider groups use enhanced FFS and PMPM payment structures to reimburse primary care practices that reach a specified level of medical home or meaningful use standards. ➤ One Medicaid coordinated care program had almost $1 billion in reduced spending over 4 years. ➤ Another PCMH payer program had an approximate 28% reduction in acute care hospital admissions among Medicare beneficiaries and an approximate 38% reduction in admissions among commercial beneficiaries. ➤ By adopting and paying for PCMHs, health plans can play an important role in transforming the US healthcare system, as well as better position themselves for long-term corporate success. ➤

Reineking, NCQA’s Director of Clinical Recognition Programs, in a January 8, 2013, telephone interview. “Practice size varied, but about 50% of those recognized were large sites, likely primary care practices from integrated health systems,” she said. The NCQA’s 2011 guidelines include 6 standards, each with a number of elements, for practices to meet.7 Within these 6 standards, there are several must-pass elements for which a practice must earn at least 50% of the total possible points. These 6 standards are7: 1. Enhance access and continuity 2. Identify and manage patient populations 3. Plan and manage care 4. Provide self-care support and community resources 5. Track and coordinate care 6. Measure and improve performance. Based on their point totals in those categories, practices can earn 3 levels of recognition: level 1 (35-59 points), level 2 (60-84 points), and level 3 (85-100 points).8 To achieve the highest levels of PCMH recognition, practices must have electronic health record (EHR) systems for activities such as patient and population management. The NCQA aligned its 2011 standards with the “meaningful use” standards from the Office of the National Coordinator for Health Information, which is part of the US Department of Health and Human Services.

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American Health & Drug Benefits

business

Practices with clinicians demonstrating meaningful use standards will also receive credit from the NCQA. Approximately 21,300 family practice and internal medicine specialists demonstrated meaningful use standards as of April 2012, receiving on average approximately $17,000 per practice from the Centers for Medicare & Medicaid Services (CMS) EHR incentives program.9 In addition, more than 13,800 nurse practitioners have enrolled in the CMS incentives program as of April 2012.9

The ACA’s policies are expected to increase the importance of and the demand for primary care services, particularly for people who are newly enrolled in Medicaid. Challenges to Promoting Medical Homes and Primary Care PCMHs and PCP practices in general face a number of barriers to growth. Yet, the medical home model will likely become an increasingly important way to curb healthcare costs as millions more people across the country become newly insured as a result of the ACA. Primary Care Reimbursement The first hurdle is that reimbursement for primary care tends to follow the fee-for-service (FFS) model, and often at lower rates than used for specialist care. For example, in a personal interview on May 8, 2012, Sunanda Sindhwani, MD, of Internal Medicine Associates, Reston, VA, said that at her practice, which treats approximately 10,000 patients in Fairfax County, VA (and has one of the highest county median incomes in the nation10), the practice’s reimbursement level has changed by only a small amount in the past 5 years. Practice reimbursement is still almost exclusively based on FFS, with commercial plans paying a slightly higher amount than Medicare. Notably, as a sign of the recognition of primary care reimbursement as a problem, the ACA required state Medicaid programs to reimburse PCPs at no less than 100% of Medicare’s reimbursement rate in 2013 and 2014.11 The ACA also provides a 10% Medicare incentive payment for primary care services.12 PCMH Certification and Health Information Technology The NCQA certification for PCMHs has tremendous value as a uniform, nationally recognized set of standards. Achieving NCQA’s certification, however, is often challenging for PCP practices, which must invest significant amounts of resources and uncompensated staff time to

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complete the process. Randall Curnow, Jr., MD, MBA, Executive Vice President and Chief Medical Officer of Summit Medical Group in Knoxville, TN, commented in an April 26, 2012, interview that achieving even the 2008 NCQA standards, which are considerably less challenging than the 2011 standards, required as many as 100 hours in addition to the day-to-day patient care. The technologic requirements for PCMH certification also can be daunting. In a May 1, 2012, telephone interview, Joel C. White, Executive Director of the Health IT Now Coalition, commented that “Stage 1 represents a fairly low bar.” The stage 1 meaningful use measures focus on basic electronic tools, such as e-prescribing, computerized physician order entry, clinical decision support, and recording basic demographic information. Stage 2 standards, however, are more challenging and require information sharing to allow for care coordination using point-to-point messaging. “Lack of interoperability, for example, between a [PCP] practice and hospitals or with specialists’ practices is a significant problem, although it is not a technology or standards issue,” Mr White indicated. Dr Sindhwani reinforced the value of interoperability, particularly as a way to avoid redundancy in services, such as duplicate magnetic resonance imaging or laboratory tests. With the majority of PCP practices being relatively small, and particularly for practices in rural health provider shortage areas, the challenges of moving to an accredited meaningful use EHR system may well be significant, and may “disrupt workflow,” he noted.

Effects of the ACA The ACA’s policies are expected to increase the importance of and the demand for primary care services, particularly for people who are newly enrolled in Medi caid. The Supreme Court’s decision in NFIB v Sebelius gave states a choice of whether to expand Medicaid eligibility up to 138% of the federal poverty level starting in 2014.13 The estimates vary widely for how many new people Medicaid programs will enroll. The Congressional Budget Office’s latest projection, after the Supreme Court’s decision, estimates that 11 million people will become newly insured through Medicaid by 2022, 6 million fewer than it had projected before the Supreme Court’s decision.14 However, of those 6 million, 50% are expected to get coverage through state health insurance exchanges and the other 50% are expected to be uninsured.14 The Kaiser Commission on Medicaid and the Uninsured estimates that 21.3 million people would become newly enrolled in Medicaid if all states choose to expand the program.15 The combination of people who become newly in-

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sured, as well as general population growth and aging demographics, will create an additional demand for primary care services. One recent study projected that those factors would increase the number of annual primary care visits from 462 million in 2008 to 565 million in 2025.16

Successful Models to Promote Medical Homes, Improve Quality, and Reduce Costs Health plans have an opportunity to address each of the challenges described above. This section discusses several proved methods that health plans could use to support medical homes, drawn from health plans and other organizations that serve a variety of beneficiaries. At first, paying more for primary care seems at odds with the goal of reducing overall healthcare costs. However, the right kinds of PCP incentives and models have proved to reduce the use of expensive medical services and cut costs. We review those models and then discuss their results. We divided the incentive methods into 2 broad categories—enhanced payments for high-quality primary care and care coordination. Examples of Enhanced Payments for High-Quality Primary Care The payment incentives we examined involved a few basic models: • Enhanced FFS payments based on NCQA and meaningful use certifications • Supplementary payments, frequently on a per-member per-month (PMPM) basis • Value-based payment methods, or pay-for-performance (P4P) payments • Gain-sharing payments (which are less frequently used). A 2010 study of PCMH pilot projects showed that medical homes used a variety of payment models, often mixing multiple kinds of payments.17 For example, typical FFS and PMPM payments were ubiquitous, with 96% of the programs in the study using each of them. Of these programs, 58% had PMPM payments that were adjusted based on the NCQA accreditation level attained and 23% had payments adjusted for risk. The mean annual additional PMPM payment was $22,834 per physician. (This amount represents the mean high and low. The full range of PMPM payments was between $720 and $91,146.17) Such results mirror the mixture of incentive payment methods in the examples we discuss for this article. Geisinger Health System. Geisinger Health Plan’s medical home model—ProvenHealth Navigator—is “an intensive multidimensional medical home model that addresses care delivery and financing.”18 Janet Tomcavage, RN, MSN, Geisinger’s Health System Chief Clinical Transformation Officer, said in a May 2, 2012, telephone

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interview that the program follows a “value-based reimbursement model,” which includes FFS and performance-based PMPM payments. Practices can earn up to 3 P4P stars, which are based on quality indicators, such as Healthcare Effectiveness Data and Information Set (HEDIS) measures, emergency department utilization, and medication adherence. The performance-based payments can reach $6 PMPM. Ms Tomcavage illustrated that a 3-star practice with 1000 Geisinger Health Plan members could earn an additional P4P payment of $6000 monthly, or $72,000 annually.

Paying more for primary care seems at odds with the goal of reducing overall healthcare costs. However, the right kinds of PCP incentives and models have proved to reduce the use of expensive medical services and cut costs. In the same interview, Ms Tomcavage said that Geisinger’s model also includes “quality gated results sharing.” Practices receive a portion of the estimated cost-savings if, compared with the previous 2 years, they meet targets for efficiency and medical expenses. Practices must also show improvement in quality measures, such as better patient outcomes in diabetes and cardiovascular disease, and enhanced patient satisfaction. BCBS of North Carolina. Blue Cross Blue Shield (BCBS) of North Carolina is another health plan that has been successful in promoting medical homes. Through its Blue Quality Physician Program, it provides an approximately 25% enhancement to fee schedule payments for practices serving as medical homes and for practices making other clinical improvements. During the 3-year pilot project leading up to the Blue Quality program, BCBS of North Carolina paid financial rewards to physicians who achieved NCQA performance measures. A separate BCBS of North Carolina program helps PCPs to develop EHRs and to demonstrate meaningful use standards. Demonstrating meaningful use standards allows PCP practices to receive substantial incentive payments, often approximately $17,000, from CMS.9 Summit Medical Group. An example of a provider group that has embraced the PCMH model and benefited from enhanced quality- and certification-based payments is Summit Medical Group. The group has approximately 220 physicians (almost exclusively PCPs) with level 3 NCQA certification, and is recognized as a top practice in the NCQA’s certifications for diabetes, heart, and stroke care. Dr Curnow believes that the healthcare industry is moving from an FFS model to a “fee-for-val-

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Figure 1 Community Care of North Carolina Cost-Savings to the North Carolina Medicaid Program Total annual savings, $ millions

Per member per month $30

$450

291% 4-year savings growth

$25

$16

$250 $204

$200 $150

$100

$5 $0

$295

$300

$20

$10

$382

$350

$21

$15

$984 million total estimated savings

$400

$25

$103

$50 FY07

FY08

FY09

FY10

FY07 FY08 FY09 FY10

FY indicates fiscal year. Source: Reference 5.

ue” model, with P4P and gain-sharing. Dr Curnow expects that in the next few years a substantial portion of Summit Medical Group’s revenue will be related to its NCQA accreditations, meaningful use criteria, and its gain-sharing payments.

Community Care of North Carolina’s PCMH is one of the best-known examples of how care coordination can improve outcomes and reduce costs for Medicaid beneficiaries. Summit Medical Group recently sought relationships with commercial insurers who were interested in making value-based FFS payments. Those relationships have led to significantly enhanced FFS payments for its commercial and Medicare Advantage populations as a result of Summit’s verified quality, size, and market power, Dr Curnow noted. The practice also receives payments based on its NCQA and meaningful use certifications. In addition, the group is seeking gain-sharing programs with some of its commercial insurers. Gain-sharing typically provides practices with savings based on how actual costs compare with the expected risk-adjusted costs of their beneficiary population. Dr Curnow expects gain-sharing to be adjusted, including potential reductions, based on patient satisfaction and quality scores, such as performance on preventive care, care coordination, and selected HEDIS measures.

Care Coordination and Management In addition to enhanced payments for quality mea-

American Health & Drug Benefits

sures, health plans and other organizations have made additional payments to promote care coordination, which is a fundamental component of PCMHs. In the Geisinger Health Plan model, Ms Tomcavage noted that “case management is embedded in the practices.” Case managers are registered nurses who are Geisinger Health Plan employees and who are physically located in practices with other team members. Geisinger Health System (the parent company of Geisinger Health Plan) also has superb information technology that links health system components, such as practices, hospitals, and laboratories. The system provides substantial and valuable data for the case managers, practices, and physicians who use these data for patient and population management. CCNC. Community Care of North Carolina (CCNC)’s PCMH is one of the best-known examples of how care coordination can improve outcomes and reduce costs for Medicaid beneficiaries. CCNC consists of 14 locally owned and locally led care networks. As Paul Mahoney, Director of Communications at CCNC, stated in an April 17, 2012, interview and in personal communications, the networks allow CCNC to tailor its services to North Carolina’s diverse geography and populations, and CCNC staff members consider the networks to be an important part of CCNC’s success. Local ownership and control also help to achieve a high level of buy-in from physicians and their practices. The state Medicaid program pays primary care practices 95% of Medicare’s reimbursement rates and makes PMPM payments of $2.50 for beneficiaries who are women and children and $5 for beneficiaries who are elderly, blind, and disabled. North Carolina also gives

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eduction in Hospital Admissions and Emergency Department Visits: Geisinger’s ProvenHealth Figure 2 R Navigator Members versus Control Groupa Acute admissions

Emergency department visits

350,000

300,000

250,000

–8%b

250,000

–28%b

200,000

150,000

100,000

100,000 –38%c

50,000

–34%c

50,000

l er m m Co

cia

tor

e dic

m Co

ra pa

er m m Co

tor

l cia

tor m

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Control group includes Geisinger members who are not in the ProvenHealth Navigator medical home. Percent reduction in Medicare members versus comparator group. Medicare beneficiaries are from Geisinger Health Plan’s Medicare Advantage population. c Percent reduction in commercial members versus comparator group. Source: Reference 19. a

CCNC networks a variable PMPM payment of between $3 and $11, depending on the populations enrolled. These payments fund care coordination, care management, and quality improvement. CCNC has 600 care managers who are embedded in medical practices and hospitals, and sometimes in emergency departments, according to Mr Mahoney. Pharmacists are also important participants in CCNC networks, because they support medical practices through medication management and reconciliation. CCNC pharmacists combine patient feedback and clinical data with prescription and claim data to produce comprehensive patient drug profiles. The profiles improve medication adherence and give clinicians a more complete view of their patients’ progress. CCNC now has interventions that identify and focus on the highest-need and highest-cost Medicaid beneficiaries, which include approximately 1% of women and children and 3% to 4% of elderly, blind, and disabled beneficiaries, according to Mr Mahoney. PMPM payments to Medicaid providers and CCNC networks allow for concerted efforts to reduce major cost-drivers, such as preventable readmissions, psychiatric readmissions, inpatient costs, and the overall cost of the elderly, blind,

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and disabled population. CCNC also focuses on patients with behavioral and chronic conditions, who may need extra support and for whom care is often expensive. Vermont Blueprint for Health. An example of a statewide multi-insurer PCMH program is Vermont Blueprint for Health. In addition to its primary care network, it employs additional, locally based community provider teams, including nurse coordinators, behavioral health providers, and social workers who support multiple practices.4 Those providers know the local resources and connections, and can therefore help to integrate community agencies or other resources into the patients’ care. MDVIP. The final coordinated care model considered in this review is the MDVIP program, a national “concierge” program. MDVIP members pay an annual fee of $1500 and are paired with PCPs in the MDVIP program who give enhanced personalized care, develop wellness plans, and help to manage chronic or acute conditions. Keith W. Michl, MD, FACP, a physician in Manchester Center, VT, with 30 years in practice, said in an April 26, 2012, telephone interview that he had considered leaving clinical medicine or moving to an area where primary care reimbursement was better. Instead, he chose to join MDVIP and reduced his prac-

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tice size from 2000 patients to 500 patients. His patients now include self-employed people, some of whom have foregone health insurance in the past because of its cost, as well as wealthy retirees and teachers. Dr Michl receives approximately $1000 of each patient’s annual MDVIP fee. Having an MDVIP practice, he said, allows him to spend more time with his patients, to communicate with them via e-mail and phone, as well as after hours, and also to do more disease management, such as nutrition and lifestyle counseling.

CCNC is generating savings from an intensive patient-centric focus on high-cost beneficiaries and savings of approximately 15% per beneficiary 6 months after their enrollment in CCNC. Results of PCMH Models Data from PCMH models demonstrate the clinical and cost benefits of the PCMH model for members with commercial, Medicaid, or Medicare coverage. As shown in Figure 1, (page 34), CCNC has generated substantial estimated savings for the North Carolina Medicaid program.5 In addition, CCNC is generating savings from an intensive patient-centric focus on highcost beneficiaries and savings of approximately 15% per beneficiary 6 months after their enrollment in CCNC, according to Mr Mahoney. With 4 million members in 39 states receiving care in primary care medical homes, BCBS has been a leader in the move to the PCMH model.4 In one of the BCBS of North Carolina programs—Blue Quality Physician Program—patients who belonged to NCQA-recognized PCMHs had 52% fewer visits to specialists and 70% fewer emergency department visits.4 For Horizon BCBS of New Jersey’s PCMH, the PMPM costs were reduced by 10%, and 26% fewer emergency department visits and 21% fewer inpatient admissions were reported in 2012.4 Similarly, BCBS of Nebraska’s PCMH had 27% fewer emergency department visits and 10% fewer hospitalizations in 2012.4 Other programs have shown similar results for Medicare Advantage, traditional Medicare, and commercial insurance beneficiaries. For example, Geisinger Health Plan’s ProvenHealth Navigator medical home model significantly reduced the use of costly hospital-related services for the program’s patients (Figure 2, page 35).19 Acute admissions were reduced by 28% for Medicare members in the ProvenHealth Navigator medical home compared with those not in the medical home. Similarly, a 38% reduction was seen among commercial members in the

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ProvenHealth Navigator medical home versus those who were not (Figure 2). Intermountain Healthcare, an integrated health system in Utah, has a medical home model called “Care Management Plus.” For Care Management Plus patients, the odds of dying in the first and second years of participating in the program were significantly less for all patients, with greater benefits for patients with diabetes (at 1 year 6.2% vs 10.6% for all patients with diabetes in the control group, at 2 years 21.0% vs 24.2% for patients with diabetes in the control group).20,21 The odds of admission for any cause were reduced by 27% to 40%.20

A Call to Action Healthcare plans covering the gamut of patient populations have an opportunity to improve care and to reduce costs for their beneficiaries by taking steps to support the growth and the evolution of PCP practices and PCMHs. Based on our review of the plans discussed in this article, we recommend the following 6 actions that health plans can take to achieve these goals. 1. Get Feedback from PCPs Managed care organization executives involved with network management should have frank and open conversations with PCPs representing a variety of practices with varying sizes and locations to learn from their experiences. Doing so will help health plans to craft policies that strengthen networks by retaining PCPs, who are vital to improving care and to reducing costs. 2. Create Value-Based PCP Reimbursement Enhanced and value-based reimbursement policies for PCPs, particularly those in PCMHs, are vital to improving care and to reducing costs. We recommend that: • Commercial insurer and Medicare Advantage FFS payments for primary care services are roughly 10% higher than Medicare payments; the ACA requires state Medicaid programs to reimburse PCPs at no less than 100% of Medicare’s reimbursement rate in 2013 and 2014 • Enhanced PMPM payments to practices that meet higher levels of NCQA accreditation and CMS meaningful use standards, or for smaller or rural practices or older physicians, other medical home models, HEDIS scores, use of nonphysician providers, health information technology infrastructure, and expanded patient access • Gain-sharing or bonuses when cost-savings are demonstrated, which can be actuarially imputed or otherwise estimated • Substantial total increased payments, representing as much as a 20% increase in payment.

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Vol 6, No 1

Primary Care Medical Homes

3. Encourage Biannual Visits with High-Risk Patients Pay practices an enhanced FFS payment, of roughly $125 to $150, for biannual visits for patients whom practices or plans identify as being at a moderate or an increased risk based on their health status. 4. Fund Case Managers for High-Risk Patients Assist PCPs in identifying the 2% to 5% of patients who have the highest morbidity and costs. Then identify a provider who can be an overall case manager for the care of those patients and help to identify or to provide resources for patient and practice assistance. 5. Consider Medicaid Coordinated-Care Models With the dramatic expansion of Medicaid under the ACA, it will be particularly important to consider models, such as CCNC, that have reduced costs.5 6. Promote ACA Provisions that Support Primary Care Health plans should advocate that the components of the ACA that support primary care are brought forward and funded, whether as ACA components or as separate bills.22 Conclusion The cost of healthcare in the United States presents a tremendous burden to all stakeholders, including federal and state governments, employers, commercial payers, and individuals. With millions of new health insurance beneficiaries expected in 2014 as a result of the ACA, there will most likely be an increased demand for healthcare. Primary care is the front line for delivering preventive care and the care for chronic conditions, such as diabetes, hypertension, and hyperlipidemia, which are the major drivers of morbidity, mortality, and costs. Robust primary care models, such as the PCMH model, have shown to improve outcomes; reduce the use of higher-cost resources, such as hospital admissions and emergency department visits; and lower the total costs of care. Payers’ support of primary care (eg, via enhanced payment and support for the PCMH model) is key in transforming the US healthcare system to improve healthcare quality and outcomes and to reduce the current unsustainable trajectory of growth in healthcare costs. n Author Disclosure Statement Dr Owens is a consultant to Allergan, Biogen Idec, Boston Scientific, CardioDx, Crescendo Biosciences, Eli Lilly,

Genzyme, Iroko, Johnson & Johnson, and Novocure. Ms Collins has nothing to disclose. Mr Piper has no conflicts of interest to report.

References

1. Centers for Medicare & Medicaid Services. National Health Expenditure Projections 2011-2021. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trendsand-Reports/NationalHealthExpendData/Downloads/Proj2011PDF.pdf. Accessed January 15, 2013. 2. Kaiser Family Foundation and Health Research and Educational Trust. Employer Health Benefits 2012 Summary of Findings. http://ehbs.kff.org/pdf/2012/8346.pdf. Accessed January 15, 2013. 3. State Budget Crisis Task Force. Report of the State Budget Crisis Task Force. Revised July 31, 2012. www.statebudgetcrisis.org/wpcms/wp-content/images/Reportof-the-State-Budget-Crisis-Task-Force-Full.pdf. Acessed January 15, 2013. 4. Nielsen M, Langner B, Zema C, et al. Patient-Centered Primary Care Collabora tive. Benefits of implementing the primary care patient-centered medical home: a review of cost and quality results, 2012. www.pcpcc.net/files/benefits_of_implementing_ the_primary_care_pcmh_0.pdf. Accessed January 15, 2013. 5. Cosway R, Girod C, Abbott B. Analysis of Community Care of North Carolina Cost Savings. Milliman, Inc. December 15, 2011. www.communitycarenc.org/elements/ media/files/milliman-executive-summary.pdf. Accessed April 26, 2012. 6. American Academy of Family Physicians, American Association of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. March 2007. www.aap.org/en-us/professional- resources/practice-support/quality-improvement/Documents/Joint-PrinciplesPatient-Centered-Medical-Home.pdf. Accessed January 22, 2013. 7. NCQA’s Patient-Centered Medical Home (PCMH) 2011. November 21, 2011. www.ncqa.org/Portals/0/PCMH2011%20withCAHPSInsert.pdf. Accessed January 22, 2013. 8. NCQA’s Patient-Centered Medical Home (PCMH) 2011 January 31, 2011. http://ncqa.org/Portals/0/Programs/Recognition/PCMH_2011_Overview_5.2.pdf. Accessed January 25, 2013. 9. Centers for Medicare & Medicaid Services. April 2012 EHR Incentive Program Active Registrations. www.cms.gov/Regulations-and-Guidance/Legislation/EHR IncentivePrograms/downloads/Monthly_Payment_Registration_Report_Updated. pdf. Accessed January 22, 2013. 10. Vardi N. America’s richest counties. Forbes.com. April 11, 2011. www.forbes. com/2011/04/11/americas-richest-counties-business-washington.html. Accessed January 15, 2013. 11. Centers for Medicare & Medicaid Services. Affordable Care Act Timeline. www. medicaid.gov/AffordableCareAct/Timeline/Timeline.html. Accessed January 15, 2013. 12. Centers for Medicare & Medicaid Services. MLN Matters. August 8, 2012. www. cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatters Articles/downloads/mm7060.pdf. Accessed January 15, 2013. 13. Implementing the ACA’s Medicaid-Related Health Reform Provisions After the Supreme Court’s Decision. Kaiser Family Foundation Focus on Health Reform. August 2012. www.kff.org/healthreform/upload/8348.pdf. Accessed January 15, 2013. 14. Congressional Budget Office. Estimates for the insurance coverage provisions of the Affordable Care Act updated for the recent Supreme Court decision. July 2012. www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-Coverage Estimates.pdf. Accessed January 23, 2013. 15. Holahan J, Buettgens M, Carroll C, Dorn S. The cost and coverage implications of the ACA Medicaid expansion: national and state-by-state analysis. The Urban Institute and the Kaiser Commission on Medicaid and the Uninsured. November 2012. www.kff.org/medicaid/upload/8384.pdf. Accessed January 23, 2013. 16. Petterson SM, Liaw WR, Phillips RL Jr, et al. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10:503-509. 17. Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. J Gen Intern Med. 2010;25:584-592. 18. Gilfillan R, Tomcavage J, Rosenthal MB, et al. Value and the medical home: effects of transformed primary care. Am J Manag Care. 2010;16:607-614. 19. Steele GD, Haynes JA, Davis DE, et al. How Geisinger’s advanced medical home model argues the case for rapid-cycle innovation. Health Aff (Millwood). 2010;29: 2047-2053. 20. Dorr DA, Brunker CP. Building the Medical Home: The Role of Care Manage ment Plus. http://caremanagementplus.org/publications/FinalCM+CenteronAging Feb232011Brunker.pdf. Accessed January 23, 2013. 21. Dorr DA, Wilcox AB, Brunker C, et al. The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. J Am Geriatr Soc. 2008;56:2195-2202. 22. Collins S. Primary care shortages: strengthening this sector is urgently needed, now and in preparation for healthcare reform. Am Health Drug Benefits. 2012;5:40-47.

Stakeholder Perspective on page 38

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January/February 2013

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Stakeholder Perspective

Enhancing Health Outcomes and Quality of Care with the Medical Home Model in Primary Care By Jack E. Fincham, PhD, RPh Professor of Pharmacy Practice and Administration University of Missouri-Kansas City School of Pharmacy

The passage of the Affordable Care Act (ACA) has highlighted the importance of a renewed focus on enhancing health outcomes, while also promoting the quality of care delivered with both economic and structural benefits. HEALTH PLANS: This exceptionally well-written article provides information, instruction, and guidance pertinent to how health plans, and other payers, can use primary care medical homes for multiple purposes to improve outcomes. The descriptions of currently successful models provide templates for other groups to utilize for advantageous outcomes. The examples presented in this article by Ms Collins and colleagues range from models providing enhanced fee-for-service payments to supplemental per-member per-month models, as well as value-based or pay-for-performance models. The Call to Action section of the article outlines key action steps for models that are currently in existence and for those groups that may be anticipating instituting such plans in the future. In 2010, a document written by Meyers and colleagues and published by the Agency for Healthcare Research and Quality outlined roles for medical homes and accountable care organizations from a coordination of patient care standpoint.1 Evidence of the success of such innovations has been documented, but this current article expands on this perspective to a considerable degree by citing even more informative increases in quality of care and positive outcomes that have ensued over the succeeding years. In this article by Ms Collins and colleagues, the statewide, public–private partnership known as Community Care of North Carolina is being discussed. It may further be useful to note the beneficial aspects of the North Carolina program through the incorporation of a success-

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ful primary care medical home model for the population of at-risk pregnant Medicaid beneficiaries as another example of lowering healthcare costs and improving health outcomes with the medical home model.2 PATIENTS/PROVIDERS: Economic, patient-, and provider-related benefits have been shown to materialize with patient-centered medical homes. In a comparative study carried out within the Seattle-based Group Health of Puget Sound, results indicated that patients whose care was managed via a medical home reported increased levels of patient satisfaction compared with the comparator group with no medical home involvement. In addition, physicians and other providers experienced less burnout associated with providing care, and the economic benefits were reported to be an average of $10.30 per patient per month in the study protocol over a 2-year period.3 The crucial next steps for the evaluation of the quality enhancement aspects of the ACA, as outlined in the current article by Ms Collins and colleagues, will enable further assessment and innovative components that will facilitate an evaluation of the positive application of the primary care medical home to enhance outcomes—in terms of the economic, patient, and provider components of medical homes. Enhanced quality of care should be an expected and a welcome outcome of such system changes. n 1. Meyers D, Peikes D, Genevro J, et al. The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care. Agency for Healthcare Research and Quality US Department of Health and Human Services, AHRQ Publication No. 11-M005-EF. December 2010. http://pcmh.ahrq.gov/portal/ server.pt/community/pcmh__home/1483/PCMH_Home_Papers%20Briefs%20 and%20Othe%20Resources_v2. Accessed February 2, 2013. 2. AHRQ Health Care Innovations Exchange. Statewide Medical Home Program for Low-Income Pregnant Women Enhances Access to Comprehensive Prenatal Care and Case Management, Improves Outcomes. January 2013. www.innovations.ahrq. gov/content.aspx?id=3778. Accessed February 2, 2012. 3. Reid RJ, Coleman K, Johnson EA, et al. The Group Health Medical Home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29:835-843.

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January/February 2013

Vol 6, No 1

Call for Papers Cancer Care Theme Issue American Health & Drug Benefits will be publishing a theme issue on cancer care in mid-2013

The growing focus on targeted therapies and diagnostics, and the ever-increasing cost of cancer care, require a thorough examination of current and emerging trends in oncology, focusing on benefit design, utilization, and health outcomes. Readers are invited to submit manuscripts for this issue, including original research, cost-effective analyses, evidence-based comprehensive reviews, case studies, and industry surveys/trends. All articles will undergo the journal’s rigorous peer-review process. Manuscripts must follow the format described in the Information for Authors (available at www.AHDBonline.com).

Areas of particular interest include: ➤ Benefit ➤ Best

➤ Patient

practices in oncology

➤ Cancer ➤ Cost

➤ Managing

design for cancer therapies

trends in hematology/oncology

➤ End-of-life ➤ Health

➤ Survivorship ➤ Targeted

issues

plan initiatives in oncology

and practice guidelines

➤ Personalized

considerations in cancer care

➤ Emerging

navigation initiatives

➤ Pathways

care and health disparities

toxicities of cancer therapies

medicine in oncology programs

cancer therapies

➤ Value-based

cancer care

Articles should follow the Manuscript Instructions for Authors at www.AHDBonline.com. Submit articles to editorial@engagehc.com. For more information, call 732-992-1889.

Vol 6, No 1

January/February 2012

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ANNUAL CONFERENCE

"! ! !

! Professor Rob Coleman, MBBS, MD, FRCP Yorkshire Cancer Research Professor of Medical Oncology Director, Sheffield Cancer Research Centre Associate Director, National Institute for Health Research Cancer Research Network Department of Oncology, Weston Park Hospital Sheffield, United Kingdom

* 3:00 pm - 7:00 pm

Registration

5:30 pm - 7:30 pm

Welcome Reception and Exhibits

7:00 am - 8:00 am

Symposium/Product Theater

8:15 am - 8:30 am

Welcome to the Second Annual Conference of the Global Biomarkers Consortiumâ&#x20AC;&#x201D;Setting the Stage for the Meeting Professor Rob Coleman, MBBS, MD, FRCP

8:15 am - 11:45 am

General Session I â&#x20AC;˘ Personalized Medicine in Oncology: Evolution of Cancer Therapy from Nonspecific Cytotoxic Drugs to Targeted Therapies â&#x20AC;˘ Taking Stock of Molecular Oncology Biomarkers â&#x20AC;˘ Genomics â&#x20AC;˘ Bioinformatics â&#x20AC;˘ Validating Biomarkers for Clinical Use in Solid Tumors - Professor Rob Coleman, MBBS, MD, FRCP â&#x20AC;˘ Validating Biomarkers for Clinical Use in Hematologic Malignancies Jorge E. Cortes, MD â&#x20AC;˘ The Challenges of Biomarker-Based Clinical Trials â&#x20AC;˘ Keynote Lecture: Understanding Cancer at the Molecular Level

12:00 pm - 1:00 pm

Symposium/Product Theater/Exhibits

1:15 pm - 4:30 pm

This activity is jointly sponsored by Medical Learning Institute Inc, Center of Excellence Media, LLC, and Core Principle Solutions, LLC.

General Session II â&#x20AC;˘ Introduction to Case Studies - Jorge E. Cortes, MD â&#x20AC;˘ Case Studies: Optimal, Value-Based Use of Molecular Biomarkers in Oncology: The Expertâ&#x20AC;&#x2122;s Perspective on How I Treat My Patients, Part I â&#x20AC;˘ Lung Cancer â&#x20AC;˘ Breast Cancer â&#x20AC;˘ Multiple Myeloma â&#x20AC;˘ Prostate Cancer â&#x20AC;˘ Leukemia â&#x20AC;˘ Lymphoma â&#x20AC;˘ Panel Discussion: Management Controversies and Accepted Guidelines for the Personalized Management of Solid Tumors and Hematologic Malignancies â&#x20AC;˘ Keynote Lecture: The Medical-Legal Issues Surrounding the Use of Biomarkers in Oncology

4:30 pm - 6:30 pm

Meet the Experts/Networking/Exhibits

Jorge E. Cortes, MD Chair, CML and AML Sections D.B. Lane Cancer Research Distinguished Professor for Leukemia Research Department of Leukemia, Division of Cancer Medicine The University of Texas MD Anderson Cancer Center Houston, TX

The only global meeting dedicated to advancing the understanding of value and clinical impact of biomarker research in oncology. Guided by the expertise of leaders in this field, participants will receive a thorough understanding of the current and future landscape of the relevance of tumor biomarkers and how to effectively personalize cancer care in the clinical setting.

This meeting will be directed toward medical oncologists and hematologists, pathologists, geneticists, advanced practice oncology nurses, research nurses, clinical oncology pharmacists, and genetic counselors involved in the management of patients with solid tumors or hematologic malignancies, and interested in the use of molecular tumor biomarkers to help optimize patient care.

Upon completion of this activity, the participant will be able to: â&#x20AC;˘ Assess emerging data and recent advances in the discovery of molecular biomarkers and their impact on the treatment of patients with solid tumors or hematologic malignancies â&#x20AC;˘ Discuss the role of molecular biomarkers in designing personalized therapy for patients with solid tumors or hematologic malignancies â&#x20AC;˘ Outline the practical aspects of integrating molecular biomarkers into everyday clinical practice in the treatment of patients with cancer

Grant requests are currently being reviewed by numerous supporters. Support will be acknowledged prior to the start of the educational activities.

7:00 am - 8:00 am

Symposium/Product Theater

8:15 am - 11:45 am

General Session III â&#x20AC;˘ Review of Saturdayâ&#x20AC;&#x2122;s Presentations and Preview of Today - Jorge E. Cortes, MD â&#x20AC;˘ Case Studies: Optimal, Value-Based Use of Molecular Biomarkers in Oncology: The Expertâ&#x20AC;&#x2122;s Perspective on How I Treat My Patients, Part II â&#x20AC;˘ Melanoma â&#x20AC;˘ Colorectal Cancer and Other GI Malignancies â&#x20AC;˘ MDS â&#x20AC;˘ Myeloproliferative Neoplasms â&#x20AC;˘ Keynote Lecture: Promises and Challenges of Personalized Medicine in Improving Cancer Care â&#x20AC;˘ Tumor Board: Challenging Cases in the Use of Biomarkers in Managing Solid Tumors (attendee-contributed cases) â&#x20AC;˘ Tumor Board: Challenging Cases in the Use of Biomarkers in Managing Hematologic Malignancies (attendee-contributed cases)

12:00 pm - 1:00 pm

Symposium/Product Theater/Exhibits

1:15 pm - 3:00 pm

General Session IV â&#x20AC;˘ Keynote Lecture: Making Personalized Medicine a Reality: The Realization of Genomic Medicine â&#x20AC;˘ The Future of Personalized Medicine: Measuring Clinical Outcomes â&#x20AC;˘ Cost-Effective Technologies That Can Drive Therapeutic Decision Making â&#x20AC;˘ Regulatory Perspectives on PMO â&#x20AC;˘ PMO: The Payerâ&#x20AC;&#x2122;s Perspective â&#x20AC;˘ Panel Discussion: Can We Afford PMO? A Value-Based Analysis â&#x20AC;˘ Practical Considerations in Incorporating PMO into Everyday Cinical Management â&#x20AC;˘ Reimbursement Challenges â&#x20AC;˘ Closing Remarks

3:00 pm

Departures

The Medical Learning Institute Inc designates this live activity for a maximum of 12.5 AMA PRA Category 1 Creditsâ&#x201E;˘. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Medical Learning Institute Inc and the Center of Excellence Media, LLC. The Medical Learning Institute Inc is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Medical Learning Institute Inc Provider approved by the California Board of Registered Nursing, Provider Number 15106, for 12.5 contact hours.

The Medical Learning Institute Inc is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Completion of this knowledge-based activity provides for 12.5 contact hours (1.25 CEUs) of continuing pharmacy education credit. The Universal Activity Number for this activity is (To be determined).

CONFERENCE REGISTRATION

EARLY BIRD REGISTRATION NOW OPEN! $175.00 until June 30, 2013

www.globalbiomarkersconsortium.com

*Agenda is subject to change.

P O

PERSONALIZED MMEDICINE IN ONCOLOGY

â&#x20AC;˘ Melanoma â&#x20AC;˘ Basal Cell Carcinoma â&#x20AC;˘ Cutaneous T-Cell Lymphoma â&#x20AC;˘ Squamous Cell Carcinoma â&#x20AC;˘ Merkel Cell Carcinoma

July 26-28, 2013

Hyatt Regency La Jolla â&#x20AC;˘ San Diego, California

PROGRAM OVERVIEW

CONFERENCE CO-CHAIRS

A 2-day congress dedicated to informing, educating, and fostering the exchange of clinically relevant information in the field of cutaneous malignancies on topics in melanoma, basal cell carcinoma, cutaneous T-cell lymphoma, squamous cell carcinoma, and Merkel cell carcinoma, including: â&#x20AC;˘ Epidemiology and genetic/environmental factors â&#x20AC;˘ Molecular biology and cytogenetics related to the pathogenesis of cutaneous malignancies â&#x20AC;˘ Risk stratification based on patient and tumor characteristics â&#x20AC;˘ Principles of cancer prevention of melanoma and basal cell carcinoma â&#x20AC;˘ Current treatment guidelines â&#x20AC;˘ Emerging treatment options for personalized therapy â&#x20AC;˘ Future strategies in management based on translational data from current clinical trials and basic research

LEARNING OBJECTIVES Upon completion of this activity, the participant will be able to: â&#x20AC;˘ Review the molecular biology and pathogenesis of cutaneous malignancies as they relate to the treatment of cutaneous T-cell lymphoma, basal cell carcinoma, Merkel cell tumors, and malignant melanoma â&#x20AC;˘ Compare risk stratification of patients with cutaneous malignancies, and how to tailor treatment based on patient and tumor characteristics â&#x20AC;˘ Summarize a personalized treatment strategy that incorporates current standards of care and emerging treatment options for therapy of patients with cutaneous malignancies

TARGET AUDIENCE This activity was developed for medical and surgical oncologists, dermatologists, radiation oncologists, and pathologists actively involved in the treatment of cutaneous malignancies. Advanced practice oncology or dermatololgy nurses, oncology pharmacists, and researchers interested in the molecular biology and management of cutaneous malignancies are also encouraged to participate.

DESIGNATION OF CREDIT STATEMENTS SPONSORS This activity is jointly sponsored by Medical Learning Institute Inc, Center of Excellence Media, LLC, and Core Principle Solutions, LLC.

COMMERCIAL SUPPORT ACKNOWLEDGMENT Grant requests are currently being reviewed by numerous supporters. Support will be acknowledged prior to the start of the educational activities.

Sanjiv S. Agarwala, MD Professor of Medicine Temple University School of Medicine Chief, Oncology & Hematology St. Lukeâ&#x20AC;&#x2122;s Cancer Center Bethlehem, Pennsylvania

REGISTERED NURSE DESIGNATION Medical Learning Institute Inc Provider approved by the California Board of Registered Nursing, Provider Number 15106, for 12.0 contact hours.

REGISTERED PHARMACY DESIGNATION The Medical Learning Institute Inc is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Completion of this knowledge-based activity provides for 12.0 contact hours (1.2 CEUs) of continuing pharmacy education credit. The Universal Activity Number for this activity is (To be determined).

CONFERENCE REGISTRATION EARLY BIRD REGISTRATION NOW OPEN! $175.00 UNTIL APRIL 30, 2013

www.CutaneousMalignancies.com

Professor Dr. Med. Axel Hauschild Professor, Department of Dermatology University of Kiel Kiel, Germany

AGENDA* FRIDAY, JULY 26, 2013 3:00 pm â&#x20AC;&#x201C; 7:00 pm

Registration

5:30 pm â&#x20AC;&#x201C; 7:30 pm

Welcome Reception/Exhibits

SATURDAY, JULY 27, 2013 7:00 am â&#x20AC;&#x201C; 8:00 am

Breakfast Symposium/Product Theater/Exhibits

8:00 am â&#x20AC;&#x201C; 8:15 am

BREAK

8:15 am â&#x20AC;&#x201C; 8:30 am

Welcome to the Second Annual World Cutaneous Malignancies Congress â&#x20AC;&#x201D; Setting the Stage for the Meeting - Sanjiv S. Agarwala, MD

8:30 am â&#x20AC;&#x201C; 11:45 am General Session I: A Clinicianâ&#x20AC;&#x2122;s Primer on the Molecular Biology of Cutaneous Malignancies â&#x20AC;˘ Keynote Lecture Understanding the Basic Biology and Clinical Implications of the Hedgehog Pathway â&#x20AC;˘ Keynote Lecture Pathogenesis of Merkel Cell Carcinoma: An Infectious Etiology? - Paul Nghiem, MD, PhD 12:00 pm â&#x20AC;&#x201C; 1:00 pm Lunch Symposium/Product Theater/Exhibits 1:00 pm â&#x20AC;&#x201C; 1:15 pm

BREAK

1:15 pm â&#x20AC;&#x201C; 4:30 pm

General Session II: Current Treatment Guidelines in Cutaneous Malignancies â&#x20AC;˘ Case Studies Optimal, Value-Based Therapy of Cutaneous Malignancies: The Expertâ&#x20AC;&#x2122;s Perspective on How I Treat My Patients â&#x20AC;˘ Panel Discussion Management Controversies and Accepted Guidelines for the Personalized Management of Cutaneous Malignancies â&#x20AC;˘ Keynote Lecture New Combinations in Melanoma: A Role for MEK + BRAF and Antiâ&#x20AC;&#x201C;PD-1

4:30 pm â&#x20AC;&#x201C; 6:30 pm

Meet the Experts/Networking/Exhibits

PHYSICIAN CREDIT DESIGNATION The Medical Learning Institute Inc designates this live activity for a maximum of 12.0 AMA PRA Category 1 Credits â&#x201E;˘. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Medical Learning Institute Inc and the Center of Excellence Media, LLC. The Medical Learning Institute Inc is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Steven J. Oâ&#x20AC;&#x2122;Day, MD Hematology/Oncology Director of Clinical Research Director of Los Angeles Skin Cancer Institute at Beverly Hills Cancer Center Clinical Associate Professor of Medicine USC Keck School of Medicine Los Angeles, California

SUNDAY, JULY 28, 2013 7:00 am â&#x20AC;&#x201C; 8:00 am

Breakfast Symposium/Product Theater/Exhibits

8:00 am â&#x20AC;&#x201C; 8:15 am

BREAK

8:15 am â&#x20AC;&#x201C; 8:30 am

Review of Saturdayâ&#x20AC;&#x2122;s Presentations and Preview of Todayâ&#x20AC;&#x2122;s Sessions

8:30 am â&#x20AC;&#x201C; 11:45 am General Session III: Review of Emerging Treatment Options for Cutaneous Malignancies General Session IV: Challenges for the Cutaneous Malignancies Clinician â&#x20AC;˘ Panel Discussion How Can the Healthcare Team Work Best Together to Deliver Value-Based Care in Cutaneous Malignancies? 12:00 pm â&#x20AC;&#x201C; 1:00 pm Lunch Symposium/Product Theater/Exhibits 1:00 pm â&#x20AC;&#x201C; 1:15 pm

BREAK

1:15 pm â&#x20AC;&#x201C; 2:45 pm

General Session V: â&#x20AC;&#x153;Hot Dataâ&#x20AC;? â&#x20AC;&#x201D; What I Learned at Recent Meetings: Focus on Cutaneous Malignancies

2:45 pm â&#x20AC;&#x201C; 3:00 pm

Closing Remarks - Steven J. Oâ&#x20AC;&#x2122;Day, MD

*Agenda is subject to change.

For complete agenda please visit www.CutaneousMalignancies.com

Policy Update

HIPAA Privacy and Security Regulations Updated By Ross D. Margulies, JD, MPH, and Jayson Slotnik, JD, MPH

n January 17, 2013, nearly 3 years after its initial proposed rule, the US Department of Health and Human Services (HHS) issued the long-awaited and much-anticipated Health Insurance Portability and Accountability Act (HIPAA) “omnibus” rule, extending the scope of the privacy law beyond healthcare providers to their business associates and subcontractors, and adding increased penalties for noncompliance.1 Regulated entities must be in compliance with the new rules by September 22, 2013, although covered entities and business associates will have up to 1 year after the 180-day compliance date to modify existing contracts to comply with these revised rules. All provider practices and health plans should begin to examine their policies now to ensure a seamless transition to these new rules.

All provider practices and health plans are now tasked with the arduous effort of implementing what the HHS is calling “the most sweeping changes to the HIPAA privacy and security rules since they were first implemented.” Among the most dramatic changes to the existing law is that HIPAA’s privacy and security requirements will now directly apply to business associates. Business associates will now include health information organizations, e-prescribing gateways, other entities that provide data transmission services for covered entiMr Margulies is an Associate at Foley Hoag, LLP, Washington, DC; Mr Slotnik is a Partner, Health Policy Strategies, LLC, Washington, DC.

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ties and that require access to data on a routine basis, entities that offer a personal health record to individuals on behalf of a covered entity, and subcontractors. Penalties for noncompliance will range in severity, depending on the degree of culpability, including the number of individuals affected, and whether the noncompliant body has a history of noncompliance. Central to the new regulations—which total a whopping 563 pages—is the sharing of patient-protected health information. Patients are given new control over their patient-protected health information, including allowing patients to request a copy of their electronic medical record in an electronic format and permitting patients to instruct their provider not to share information about treatment with their health plan when the individual pays for that care out of pocket. In addition, the final rule expands the definition of a “breach” under HIPAA, thus eliminating the “harm” standard, which previously allowed entities to avoid breach notification if they could demonstrate that the breach posed no significant risk of harm to the individual. Under the new rule, any impermissible use or disclosure of patient-protected health information is presumed a breach, “regardless of whether the information is being held by a health plan, a healthcare provider, or one of their business associates,”1 unless a low probability that information has been compromised can be demonstrated. All provider practices and health plans are now tasked with the arduous effort of implementing what the HHS is calling “the most sweeping changes to the HIPAA privacy and security rules since they were first implemented.”1 n

Reference

1. US Department of Health and Human Services. New Rule Protects Patient Privacy, Secures Health Information. Press Release. January 17, 2013. www.hhs.gov/news/ press/2013pres/01/20130117b.html. Accessed February 2, 2013.

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January/February 2013

Vol 6, No 1

SABCS Highlights

The Role of Personalized Medicine in the Management of Patients with Breast Cancer By Phoebe Starr

pplying the approach of personalized medicine to cancer care is gradually becoming crucial for ensuring the correct use of targeted therapies and individualizing the management of patient care. The role of genetics in breast cancer is not new, but the ever-increasing numbers of new molecular diagnostics and targeted therapies are making this disease a growing focus of personalized medicine. Several studies reported at the 2012 CTRC-AACR San Antonio Breast Cancer Symposium focused on the role of personalized medicine in breast cancer management.

BluePrint and MammaPrint Molecular Assays Reclassify Many Primary Breast Cancers

In a retrospective study of 208 patients with breast cancer, the use of molecular subtyping revealed that 25% of these tumors had been misclassified when diagnosed clinically, and therefore these patients should have been receiving different treatments if these molecular tests had been applied prospectively. Specifically, 39% of the breast cancers that had been classified clinically as HER2 disease should have instead been managed with therapies for luminal-type breast cancer, such as endocrine therapy, and 20% of cancers that had been classified clinically as triple-negative breast cancer should have received therapies for luminal and HER2 disease (eg, endocrine therapy and trastuzu mab-based regimens). The investigators used frozen tumor samples from 208 patients (median age, 56 years) who were managed at 2 American institutions, following the National Compre hensive Cancer Network guidelines between 1992 and 2010. The median follow-up was 11.3 years. The majority (59%) of patients had estrogen receptor– positive (ER+) or progesterone receptor–positive (PR+) cancer; 20% had HER2 phenotype, and 24% had triple- negative breast cancer, as assessed by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH). All patients had undergone lumpectomy or mastectomy with axillary staging. In this study, 2 microarray-based assays—BluePrint and MammaPrint—were used retrospectively to evaluate the clinical diagnosis performed with IHC and FISH.

The assays showed that 13 of 188 tumors that had been classified as ER+, PR+, or HER2-negative were not luminal-type cancer by BluePrint; 24 of 41 cancers clinically identified as HER2 were not shown to be so by BluePrint; and 10 of 49 triple-negative tumors were not confirmed as basal-type cancer by BluePrint. Overall, 51 patients had to be reclassified based on these molecular tests. Of these, 28 patients were reassessed for ER, PR, and HER2 status. The patients with luminal-type early breast cancer that was identified by BluePrint have excellent relapse-free survival rates of 97% for those with luminal A cancer, and 98% for patients with luminal B cancer. These findings have important clinical implications for the accurate identification of women with a specific type of breast cancer and the selection of appropriate therapy. According to lead investigator Massimo Cristofanilli, MD, FACP, Chair, Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, and colleagues, “The use of MammaPrint and BluePrint should be implemented in the management of primary breast cancer for the selection of adjuvant therapy in the era of personalized care.”

EndoPredict Identifies Women with ER+ Breast Cancer at Risk for Late Metastases

Another multigene test, EndoPredict, can help to identify women with ER+/HER2-negative breast cancer who are likely to develop metastatic disease in the longterm. EndoPredict, which is not yet available for use in the United States, is different from other molecular assays in its ability to predict later, rather than earlier, metastases, according to lead investigator Peter C. Dubsky, MD, Associate Professor, Department of Surgery, Medical University of Vienna, Austria. “Oncotype DX and other predictive tests that rely on genetic signatures are used to predict earlier recurrence within the first 5 years,” Dr Dubsky said. “It is important to be able to predict risk of late recurrence for ERpositive breast cancer, because after 5 to 10 years of follow-up, mortality rates are higher for ER-positive than for ER-negative breast cancer.” If these results are validated, then a low EndoPredict Continued on page 44

Vol 6, No 1

January/February 2013

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SABCS Highlights

score could identify the women with breast cancer who could forego extended antihormonal therapy. Unlike other multigene tests that are based solely on the molecular fingerprint of a tumor, the EndoPredict score factors in tumor biology data that are derived from tumor size and nodal status along with gene expression for 8 genes (3 proliferation genes and 5 ER-dependent genes) and 3 reference genes, similar to the techniques used in the Oncotype DX assay. This study was conducted on tumor tissue from 1702 postmenopausal women (median age, 64 years) with ER+/HER2-negative breast cancer who participated in 2 randomized trials—the Austrian Breast Cancer Study Group (ABCSG)-6 and ABCSG-8. Overall, 33% had node-positive disease. None of the women received adjuvant chemotherapy, but all of them received some form of hormonal therapy for 5 years, including tamoxifen alone or as a sequence of tamoxifen and an aromatase inhibitor. All the women had low-tointermediate clinical risk. Based on a predefined EndoPredict clinical score that combined the EndoPredict with nodal status and tumor size, 64% of the patients were determined to be at low risk for distant metastases; 98.2% of these women were free of late metastases at 10 years and were 5 times more likely to remain free of late metastases at 10 years than the 33% of women with a high EndoPredict score. Further analysis showed that the genes associated with ER signaling added independent prognostic information for late recurrence. Discussing the importance of these findings, Dr Dubsky noted that current clinical trials are not providing the type of data needed to predict late metastases. “We currently have around 20,000 women in ongoing extended/late endocrine therapy clinical trials….We see very low rates, and the efficacy data of these trials is unlikely to make individual decisions for women very simple,” Dr Dubsky said. He believes that gene-expression data extracted from EndoPredict could help to establish subgroups of patients with an excellent prognosis, which would facilitate the choice of therapy. EndoPredict is currently available for diagnostic use in Austria and Switzerland. Expanded studies are ongoing.

Triple-Negative Breast Cancer Linked to BRCA1, but Not BRCA2, Mutation

In a large study with 2105 patients with breast cancer, triple-negative breast cancer was strongly associated with the BRCA1 genetic mutation but not with BRCA2. Women with triple-negative breast cancer are thought

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to be more likely to have the BRCA genetic mutation, but it remains controversial whether newly diagnosed women with triple-negative breast cancer should be referred for genetic counseling. The recommendation for genetic counseling in this patient population is based only on studies with small numbers of BRCA carriers, and no clear guideline is available. This study was conducted by investigators at Kaiser Permanente and was based on a retrospective cohort of 2105 women with breast cancer who were tested for BRCA mutations between 1997 and 2011. The BRCArelated results were reported in the health plan’s clinical genetics registry. Of the 2105 women with breast cancer, 249 were found to be carriers of a BRCA mutation—143 had the BRCA1 mutation, and 106 had the BRCA2 mutation. Data linkages were performed for all patients with the National Cancer Institute-SEER (Surveillance, Epidemiology and End Results)– affiliated tumor registry; ER, PR, and HER2 statuses were captured and were assessed by IHC or FISH techniques. Patients were classified into the 2 main biologic subtypes of triple-negative breast cancer (ER-negative, PR-negative, HER2negative) and non–triple-negative breast cancer (luminal A, luminal B, and HER2-enriched). The association between triple-negative breast cancer and non–triple-negative breast cancer and BRCA1 or BRCA2 mutation status was then examined. The triple-negative subtype was strongly correlated with BRCA status (P <.001). Women with triple-negative tumors were 5 times more likely to be BRCA carriers than women with non–triple-negative tumors (odds ratio [OR], 5.6; 95% confidence interval [CI], 4.1-7.5). The association between triple-negative breast cancer and BRCA1 was more robust (OR, 12.2; 95% CI, 8.3-17.9) and was unchanged after adjusting for age, stage at diagnosis, and race or ethnicity. Triple-negative cancer was not associated with BRCA2 status (OR, 1.6; 95% CI, 0.9-2.7).

Conclusion These data, taken together, point to the increasing importance of personalized medicine in the daily management of patients with breast cancer. Consequently, research is needed to evaluate the cost impact of incorporating these molecular tests into clinical practice, and to compare the cost-effectiveness of these various tools, considering that more accurate diagnosis is associated with improved health outcomes and therefore often with reduced overall costs, despite the extra costs associated with the administration of the test itself. n

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January/February 2013

Vol 6, No 1

For the treatment of severe hypertriglyceridemia (TG levels ≥ 500 mg/dL)

Clearly the right choice for your formulary VASCEPA® is an optimal TG-lowering agent for your formulary and your members with severe hypertriglyceridemia. VASCEPA® is the first FDA-approved, EPA-only omega-3-fatty acid that significantly lowers median placebo-adjusted TG levels by 33% without increasing LDL-C or HbA1c compared to placebo while also positively affecting a broad spectrum of lipid parameters.1 Consider VASCEPA® an affordable option for your members with severe hypertriglyceridemia (TG levels ≥ 500 mg/dL). Indications and Usage VASCEPA® (icosapent ethyl) is indicated as an adjunct to diet to reduce triglyceride (TG) levels in adult patients with severe (≥ 500 mg/dL) hypertriglyceridemia. • The effect of VASCEPA® on the risk for pancreatitis in patients with severe hypertriglyceridemia has not been determined • The effect of VASCEPA® on cardiovascular mortality and morbidity in patients with severe hypertriglyceridemia has not been determined Important Safety Information for VASCEPA® • VASCEPA® is contraindicated in patients with known hypersensitivity (e.g., anaphylactic reaction) to VASCEPA® or any of its components • Use with caution in patients with known hypersensitivity to fish and/or shellfish

• The most common reported adverse reaction (incidence >2% and greater than placebo) was arthralgia • Patients should be advised to swallow VASCEPA® capsules whole; not to break open, crush, dissolve, or chew VASCEPA®

Reference: 1. Bays HE, Ballantyne CM, Kastelein JJ, et al. Eicosapentaenoic acid ethyl ester (AMR101) therapy in patients with very high triglyceride levels (from the multi-center, placebo-controlled, randomized, double blind, 12-week study with an open-label extension [MARINE] trial). Am J Cardiol. 2011;108:682-690. For more information on VASCEPA® see the brief summary or for the Full Prescribing Information please visit www.VASCEPA.com. Amarin Pharma Inc. Bedminster, NJ 07921 www.AmarinCorp.com

130033 1/2013

Reprint Code: XXXXXX

VASCEPA® (icosapent ethyl) Capsules, for oral use Brief summary of Prescribing Information Please see Full Prescribing Information for additional information about Vascepa. 1 INDICATIONS AND USAGE VASCEPA® (icosapent ethyl) is indicated as an adjunct to diet to reduce triglyceride (TG) levels in adult patients with severe (≥500 mg/dL) hypertriglyceridemia. Usage Considerations: Patients should be placed on an appropriate lipid-lowering diet and exercise regimen before receiving VASCEPA and should continue this diet and exercise regimen with VASCEPA. Attempts should be made to control any medical problems such as diabetes mellitus, hypothyroidism, and alcohol intake that may contribute to lipid abnormalities. Medications known to exacerbate hypertriglyceridemia (such as beta blockers, thiazides, estrogens) should be discontinued or changed, if possible, prior to consideration of TG-lowering drug therapy. Limitations of Use: The effect of VASCEPA on the risk for pancreatitis in patients with severe hypertriglyceridemia has not been determined. The effect of VASCEPA on cardiovascular mortality and morbidity in patients with severe hypertriglyceridemia has not been determined. 2 DOSAGE AND ADMINISTRATION Assess lipid levels before initiating therapy. Identify other causes (e.g., diabetes mellitus, hypothyroidism, or medications) of high triglyceride levels and manage as appropriate. [see Indications and Usage (1)]. Patients should engage in appropriate nutritional intake and physical activity before receiving VASCEPA, which should continue during treatment with VASCEPA. The daily dose of VASCEPA is 4 grams per day taken as 2 capsules twice daily with food. Patients should be advised to swallow VASCEPA capsules whole. Do not break open, crush, dissolve, or chew VASCEPA. 4 CONTRAINDICATIONS VASCEPA is contraindicated in patients with known hypersensitivity (e.g., anaphylactic reaction) to VASCEPA or any of its components. 5 WARNINGS AND PRECAUTIONS 5.1 Monitoring: Laboratory Tests In patients with hepatic impairment, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels should be monitored periodically during therapy with VASCEPA. 5.2 Fish Allergy VASCEPA contains ethyl esters of the omega-3 fatty acid, eicosapentaenoic acid (EPA), obtained from the oil of fish. It is not known whether patients with allergies to fish and/or shellfish are at increased risk of an allergic reaction to VASCEPA. VASCEPA should be used with caution in patients with known hypersensitivity to fish and/or shellfish. 6 ADVERSE REACTIONS 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Adverse reactions reported in at least 2% and at a greater rate than placebo for patients treated with VASCEPA based on pooled data across two clinical studies are listed in Table 1. Table 1. Adverse Reactions Occurring at Incidence >2% and Greater than Placebo in Double-Blind, Placebo-Controlled Trials*

Placebo (N=309) Adverse Reaction Arthralgia

VASCEPA (N=622) n %

1.0

2.3

*Studies included patients with triglycerides values of 200 to 2000 mg/dL. An additional adverse reaction from clinical studies was oropharyngeal pain. 7 DRUG INTERACTIONS 7.1 Anticoagulants Some published studies with omega-3 fatty acids have demonstrated prolongation of bleeding time. The prolongation of bleeding time reported in those studies has not exceeded normal limits and did not produce clinically significant bleeding episodes. Patients receiving treatment with VASCEPA and other drugs affecting coagulation (e.g., anti-platelet agents) should be monitored periodically. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women. It is unknown whether VASCEPA can cause fetal harm when administered to a pregnant woman or can affect reproductive capacity. VASCEPA should be used during pregnancy only if the potential benefit to the patient justifies the potential risk to the fetus. In pregnant rats given oral gavage doses of 0.3, 1 and 2 g/kg/day icosapent ethyl from gestation through organogenesis all drug treated groups had visceral or skeletal abnormalities including: 13th reduced ribs, additional liver lobes, testes medially displaced and/or not descended at human systemic exposures following a maximum oral dose of 4 g/day based on body surface comparisons. Variations including incomplete or abnormal ossification of various skeletal bones were observed in the 2 g/kg/day group at 5 times

human systemic exposure following an oral dose of 4 g/day based on body surface area comparison. In a multigenerational developmental study in pregnant rats given oral gavage doses of 0.3, 1, 3 g/kg/day ethyl-EPA from gestation day 7-17, an increased incidence of absent optic nerves and unilateral testes atrophy were observed at ≥0.3 g/kg/day at human systemic exposure following an oral dose of 4 g/day based on body surface area comparisons across species. Additional variations consisting of early incisor eruption and increased percent cervical ribs were observed at the same exposures. Pups from high dose treated dams exhibited decreased copulation rates, delayed estrus, decreased implantations and decreased surviving fetuses (F2) suggesting multigenerational effects of ethyl-EPA at 7 times human systemic exposure following 4 g/day dose based on body surface area comparisons across species. In pregnant rabbits given oral gavage doses of 0.1, 0.3, and 1 g/kg/day from gestation through organogenesis there were increased dead fetuses at 1 g/kg/day secondary to maternal toxicity (significantly decreased food consumption and body weight loss). In pregnant rats given ethyl-EPA from gestation day 17 through lactation day 20 at 0.3, 1, 3 g/kg/day complete litter loss was observed in 2/23 litters at the low dose and 1/23 middose dams by post-natal day 4 at human exposures based on a maximum dose of 4 g/day comparing body surface areas across species. 8.3 Nursing Mothers Studies with omega-3-acid ethyl esters have demonstrated excretion in human milk. The effect of this excretion is unknown; caution should be exercised when VASCEPA is administered to a nursing mother. In lactating rats, given oral gavage 14C-ethyl EPA, drug levels were 6 to 14 times higher in milk than in plasma. 8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established. 8.5 Geriatric Use Of the total number of subjects in clinical studies of VASCEPA, 33% were 65 years of age and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. 9 DRUG ABUSE AND DEPENDENCE VASCEPA does not have any known drug abuse or withdrawal effects. 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility In a 2-year rat carcinogenicity study with oral gavage doses of 0.09, 0.27, and 0.91 g/kg/day icosapent ethyl, respectively, males did not exhibit drug-related neoplasms. Hemangiomas and hemangiosarcomas of the mesenteric lymph node, the site of drug absorption, were observed in females at clinically relevant exposures based on body surface area comparisons across species relative to the maximum clinical dose of 4 g/day. Overall incidence of hemangiomas and hemangiosarcomas in all vascular tissues did not increase with treatment. In a 6-month carcinogenicity study in Tg.rasH2 transgenic mice with oral gavage doses of 0.5, 1, 2, and 4.6 g/kg/day icosapent ethyl, drug-related incidences of benign squamous cell papilloma in the skin and subcutis of the tail was observed in high dose male mice. The papillomas were considered to develop secondary to chronic irritation of the proximal tail associated with fecal excretion of oil and therefore not clinically relevant. Drug-related neoplasms were not observed in female mice. Icosapent ethyl was not mutagenic with or without metabolic activation in the bacterial mutagenesis (Ames) assay or in the in vivo mouse micronucleus assay. A chromosomal aberration assay in Chinese Hamster Ovary (CHO) cells was positive for clastogenicity with and without metabolic activation. In an oral gavage rat fertility study, ethyl-EPA, administered at doses of 0.3, 1, and 3 g/kg/ day to male rats for 9 weeks before mating and to female rats for 14 days before mating through day 7 of gestation, increased anogenital distance in female pups and increased cervical ribs were observed at 3 g/kg/day (7 times human systemic exposure with 4 g/day clinical dose based on a body surface area comparison). 17 PATIENT COUNSELING INFORMATION 17.1 Information for Patients See VASCEPA Full Package Insert for Patient Counseling Information. Distributed by: Amarin Pharma Inc. Bedminster, NJ, USA Manufactured by: Banner Pharmacaps, Tilburg, The Netherlands or Catalent Pharma Solutions, LLC, St. Petersburg, FL, USA Manufactured for: Amarin Pharmaceuticals Ireland Limited, Dublin, Ireland

Regulatory

Original Research

Medicare Part D and the Federal Employees Health Benefits Program:

A Comparison of Prescription Drug Coverage Annesha Lovett, PharmD, MS, PhD Background: There is much debate currently about how to restructure the Medicare program to achieve better value for the money. Many have cited the Federal Employees Health Benefits Program (FEHBP) as a model for reform. Objective: To compare drug coverage and cost-sharing between Medicare Part D and the FEHBP plans. Methods: A cross-sectional comparison was conducted of January 2009 data obtained from the Centers for Medicare & Medicaid Services, the Office of Personnel Management, and 3 health plan websites. Regression analysis and t-tests were used to examine drug coverage, copayment, and coinsurance amounts among Medicare Part D and FEHBP plans. The final study sample of Medicare Part D plans consisted of 19 formularies, covering 63% of total Part D enrollment. These 19 formularies represented 232 stand-alone prescription drug plans. In addition, 5 prescription drug plans or formularies in the FEHBP plans were included, which represents 70% of total FEHBP enrollment. Results: The results of this study reveal that formulary coverage of the top drugs dispensed and sold in the United States in 2009 ranged from 72% to 94% (average, 84%) in Medicare Part D plans and from 85% to 99% (average, 94%) in the FEHBP plans (P <.01). The mean copayment for generic drugs in Medicare Part D plans was $4.53 compared with a mean of $7.67 (P <.05) in the FEHBP plans. The difference between the 2 programs in mean copayment for brand-name drugs was nonsignificant. For generic drugs, the mean coinsurance rate was 17% for Medicare Part D plans and a mean of 20% for the FEHBP plans (P <.05). Conclusions: This analysis shows that there are differences in prescription drug coverage and cost-sharing among plans within Medicare Part D and the FEHBP. To avoid extreme increases in payroll taxes and other revenues or major cutbacks in services, Medicare must explore ways to change the healthcare system to achieve better value for the money. The experience of the FEHBP suggests a possible means of accomplishing this objective.

ver time, the costs associated with the Medicare program have increased steadily and have contributed to the growth in national health expenditures. For example, healthcare expenditures in the United States were almost $256 billion in 1980 and $724 billion in 1990, and they rose to $2 trillion in 2006.1 In 2009, healthcare spending was approximately $8160 per US resident and accounted for 17.6% of the nationâ&#x20AC;&#x2122;s gross domestic product (GDP); these figures were $8680 and 17.9%, respectively, in 2011.2 For

Dr Lovett is Research Assistant Professor, College of Pharmacy and Health Sciences, Mercer University, Atlanta, GA. Preliminary findings of this research were presented at the Academy Health Annual Research Meeting, June 2011, in Seattle, WA.

Vol 6, No 1

January/February 2013

Stakeholder Perspective, page 58

Am Health Drug Benefits. 2013;6(1):47-58 www.AHDBonline.com Disclosures are at end of text

Medicare alone, total expenditures in 2009 were approximately 3.5% of the GDP, or $509 billion, and are estimated to increase to 6.4% by 2084.3 To address the rising drug costs, and to provide more comprehensive healthcare coverage, the Medicare Prescription Drug, Improvement, and Modernization Act, which created Medicare Part D, was implemented in 2006.3 On its inception, more than 20 million seniors enrolled to receive prescription drug coverage.4 Medicare Part D plans are not required to include coverage for all drugs. Each plan can develop a formulary, which must include categories and classes of drugs that cover all disease states. Formularies must use the formulary that is found in the US Pharmacopeia as a model and include at least 2 drugs in 146 drug categories. Part D plans also cover biologic drugs, insulin and insulin

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REGULATORY

Key Points With the looming increase in enrollees, the Medicare program will need restructuring to improve healthcare for less money. ➤ The FEHBP has been suggested as a model for Medicare Part D, because of its cost-saving strategies and quality services, but no comparisons of these 2 programs are available regarding their drug coverage, cost-savings, and quality of care. ➤ This study compares the drug coverage and costsharing in 63% of Medicare Part D plans and 70% of the FEHBP plans. ➤ Based on this analysis, formulary coverage of the top drugs dispensed in 2009 averaged 84% in Part D plans versus an average of 94% in the FEHBP plans. ➤ Mean copayment for generic drugs in Part D plans was $4.53 compared with a mean of $7.67 in the FEHBP plans; the difference in mean copayment for brand-name drugs was not significant. ➤ Enrollment was the single strongest predictor of the number of drugs covered per therapeutic class; as enrollment increased, the number of drugs covered per therapeutic class increased ➤ To avoid cutbacks in services, Medicare must explore ways to achieve better value for the money; the experience of the FEHBP suggests a possible means of accomplishing this objective. ➤

syringes, specialty drugs, injectables, and smoking-cessation drugs. The major purpose of Medicare Part D is to provide seniors access to prescription drugs; however, many questions surrounding coverage for prescription drugs have emerged, including questions from state policymakers about the projected cost-savings in switching enrollees from other plans to Medicare Part D plans.5 In addition, concerns about Medicare funding persist, as costs continue to rise at alarming rates.6 There has been a debate over the potential benefits or consequences that may result if Medicare is reformed to resemble the Federal Employees Health Benefits Program (FEHBP).7-9 The FEHBP was created by Congress in 1959.10 The program provides healthcare coverage to active and retired federal and postal workers and their families, in addition to active and retired members of Congress and congressional staff. More than 400 private plans compete to provide coverage to more than 9 million people.10 Some have cited the program’s cost-saving techniques and provision of quality services as markers of a truly successful program.11

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A Central, Unanswered Question An unanswered question that is central to this debate is how Medicare Part D and the FEHBP prescription drug plans coverage compare. To explore this question, this study compared prescription drug coverage offered in Medicare Part D and the FEHBP in 2009. The analysis focused on the consumer perspective, by examining differences in drug coverage and cost-sharing. Specific advantages of the FEHBP include optional enrollment and broad eligibility requirements. In addition, the FEHBP uses community ratings as a disincentive for plans to determine coverage on the basis of beneficiary risk. Furthermore, the program offers more provider choice and access, increased rural access, greater achievements in cost control, and enhanced health benefits, by covering preventive services, dental services, and healthcare costs that are incurred abroad.12-14 For these reasons, the FEHBP has been cited by some as being superior to the Medicare program.10 By contrast, some reports reveal opposing views on Medicare’s adoption of an FEHBP-type model. Several studies dispute the claim that adopting an FEHBP model would offer an improvement to the Medicare program.15-17 Before the implementation of Medicare Part D, the lack of coverage for prescription drugs made the FEHBP particularly attractive in comparison with Medicare. Now that Medicare Part D has been implemented, however, the debate has been renewed on the desirability of switching enrollees from Medicare to an FEHBP-type plan.18 Methods Medicare Part D Data Collection Data were obtained from the Centers for Medicare & Medicaid Services (CMS) for January 2009 (changes to Medicare formulary are done once a year in January, hence the data in this study apply to the full year 2009). The initial sample of Medicare Part D prescription drug plans consisted of approximately 2500 prescription drug plans. Medicare Advantage plans were excluded, because separate data about prescription drug coverage were not available for those plans. After this exclusion, approximately 1893 stand-alone prescription drug plans remained. The percent and the cumulative percent of enrollees within each plan were calculated, and the plans were then ranked in terms of total enrollment. Beginning with the plans with the largest enrollment, the plans representing 63% of total Part D enrollment were selected for further consideration, resulting in a total of 232 stand-alone prescription drug plans. For the excluded plans representing 37% of total enrollment, the range of enrollment was 16,697 to

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January/February 2013

Vol 6, No 1

Medicare Part D and the FEHBP: Prescription Drug Coverage

edicare Part D and the Federal Employees Health Benefits Program Plans Selected for Analysis, Table 1 M January 2009 Total enrollment (as of January 2009), N

Total enrollment,a %

Cumulative %

Plans per formulary, N

2,716,518

15.6

Advantage Star Plan by RxAmerica

299,956

1.6

17.2

Blue MedicareRx

285,869

1.6

18.8

BlueRx

99,729

0.6

19.4

BravoRx

82,585

0.5

19.9

134,285

0.8

20.7

1,041,610

6.2

26.9

First Health Part D Premier

277,085

1.6

28.5

Health Net Orange

343,495

1.9

30.4

HealthSpring Prescription Drug Plan

171,719

0.9

31.3

Humana PDP Enhanced or Complete

1,432,200

8.2

39.5

Humana PDP Standard

1,445,988

8.1

47.6

Medco Medicare Prescription Plan

211,477

1.2

48.8

Medicare BlueRx Option 3

298,839

1.7

50.5

Prescription Pathway Bronze Plan

314,664

1.7

52.2

SilverScript Value

353,491

2.1

54.3

AARP MedicareRx Saver or UnitedHealth Rx Basic

831,943

4.9

59.2

WellCare Classic or Signature

476,022

2.6

61.8

WellCare Classic or Signature

200,462

1.2

63.0

2,020,621

50.2

Blue Cross and Blue Shield Basic Service Benefit Plan

391,541

9.7

59.9

GEHA Benefit Plan

215,833

5.4

65.3

NALC Health Benefit Plan

95,481

2.4

67.7

American Postal Workers Union Health Plan

81,626

2.0

69.7

Formulary Medicare Part D formularies AARP MedicareRx Preferred

CIGNA Medicare Rx - Plan One Community CCRx Basic

FEHBP formularies Blue Cross and Blue Shield Standard Service Benefit Plan

Medicare Part D total enrollment across all plans was 17,313,409; FEHBP total enrollment across all plans was 4,026,575. FEHBP indicates Federal Employees Health Benefits Program; GEHA, Government Employees Health Association; NALC, National Association of Letter Carriers; PDP, prescription drug plan.

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January/February 2013

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American Health & Drug Benefits

REGULATORY

Figure Algorithm Used to Create the Covered Drug List Initial 400 drugs Top 200 drugs most frequently used by dispensed prescriptions and the top 200 most frequently used drugs by US sales (from IMS Health)

400 drugs minus 74 drugs = 326 drugs When drug name was found on both lists (ie, dispensed prescriptions and sales), the drug name was only listed once

326 drugs minus 60 drugs = 266 drugs Brand-name drugs with generic equivalents were added to the list; if a brand-name drug was not listed on the formulary but its generic equivalent was, that drug was considered to be listed

on the formulary

266 drugs used in the analysis This process yielded a final list of 266 drugs, which represented a total of 23 therapeutic classes

edicare Part D and the FEHBP Formulary Coverage of Table 2 M 266 Top Drugs in the United States Medicare Part D: FEHBP: 19 formularies 5 formularies (mean ± SD) (mean ± SD) P value Percent drug coverage

84 ± 6.10

94 ± 5.93

.004

FEHBP indicates Federal Employees Health Benefits Program; SD, standard deviation.

82,585 enrollees. These plans were excluded because once enrollment was <0.5% of the total enrollment, the enrollment numbers became very small, and it was more likely that the characteristics of those smaller plans would not represent the norm. For example, CMS discussed nonrenewal of contracts that were representing a small number of enrollees.19 The organizations with low enrollment faced adverse selection concerns and a decreased ability to negotiate low drug prices.

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Examination of Part D prescription drug data revealed that multiple plans had the same formulary. Therefore, the plans were collapsed by formulary. This yielded a final study sample of 19 formularies, representing 232 stand-alone prescription drug plans, as shown in Table 1. Of note, although there are more than 1000 prescription drug plans in Part D, enrollees typically choose among 45 to 57 plans, depending on the state in which they live.20 The CMS data included prescription drug plan formulary and pharmacy network files, with formulary and pharmacy network data for all Medicare prescription drug plans as of January 2009. The data provided by CMS did not include drug names, the generic or brandname status of drugs, or therapeutic classes. The Florida Agency for Health Care Administration provided information on the drug names and the generic or brandname status of drugs. The therapeutic class was determined and entered manually using the US Pharmacopeia drug classification system.21

FEHBP Data Collection To derive the FEHBP data, a list of all plans serving beneficiaries of the FEHBP was obtained from the Office of Personnel Management for January 2009. The list included the plan name, plan type, and the number of enrollees. Additional information on the plans’ formularies was obtained from the respective plans’ websites.22-24 The initial sample of the FEHBP plans consisted of 222 prescription drug plans. These plans were ranked by total enrollment, then the percent and the cumulative percent of enrollees within each plan were calculated. Beginning with the largest enrollment, the plans representing 70% of total FEHBP enrollment were selected for the study, resulting in a total of 5 prescription drug plans and 5 formularies, as shown in Table 1. The range of enrollment for the excluded plans or formularies was 1 to 63,346 enrollees. Similar to the case for Medicare Part D, although there are more than 200 prescription drug plans, the enrollees typically choose from among 12 to 20 plans, depending on the state in which they live. Comparison Benchmark Comparison of Medicare and the FEHBP plans revealed the need for an appropriate benchmark to compare the programs. IMS Health data were chosen to obtain a list of the top 200 drugs most frequently used, based on dispensed prescriptions, and the top 200 that are the most frequently used drugs based on sales in the United States.25 When the drug name was found on either list (ie, by dispensed prescriptions and by sales), the drug name was

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edicare Part D and the FEHBP Formulary Coverage of 266 Top Drugs in the United States, by Table 3 M Therapeutic Class Total drugs in class, N

Medicare Part D formulary coverage (mean covered ± SD), %

FEHBP formulary coverage (mean covered ± SD), %

P value

65 ± 27.36

96 ± 8.94

.001

Analgesics

98 ± 3.62

98 ± 3.58

.783

Antibacterials

93 ± 7.18

96 ± 8.50

.432

Anticancer agents

77 ± 15.50

85 ± 17.07

.353

Therapeutic class ADHD agentsa

Anticonvulsants

100 ± 0

N/A

Antidementia agents

100 ± 0

93 ± 14.76

.374

Antidepressant agents

98 ± 4.19

98 ± 4.47

.961

Antipsychotic agents

98 ± 4.12

93 ± 14.76

.505

100 ± 0

N/A

0±0

95 ± 11.18

.000

93 ± 9.91

100 ± 0

.005

Blood glucose regulators

95 ± 6.62

100 ± 0

.004

Blood products/modifiers/ volume expandersb

72 ± 12.93

90 ± 18.22

.019

Cardiovascular agentsa

87 ± 8.62

97 ± 4.22

.003

74 ± 19.25

96 ± 9.84

.005

82 ± 9.36

93 ± 8.17

.019

Metabolic bone disease agentsa

85 ± 11.33

100 ± 0

.000

Multiple sclerosis agents

93 ± 11.31

100 ± 0

.021

Muscle relaxants

77 ± 15.76

80 ± 29.91

.860

72 ± 10.15

100 ± 0

.000

86 ± 9.63

98 ± 4.47

.017

Sedative/hypnotic agents

84 ± 20.33

93 ± 14.76

.292

Vaccines

83 ± 7.49

52 ± 46.04

.205

Antiretroviral/antiviral agents Anxiolytic agentsa Arthritis agents

a a

Gastrointestinal agents

Hormonal agentsb b

Ophthalmic agentsa Respiratory tract agents

Difference between group means significant at .01 confidence level. Difference between group means significant at .05 confidence level. ADHD indicates attention-deficit/hyperactivity disorder; FEHBP, Federal Employees Health Benefits Program; N/A, not available; SD, standard deviation. a

NOTE: This table lists the therapeutic classes and the mean percentages of drugs covered in that class. If <3 drugs are in a therapeutic class, that class was excluded from this analysis to ensure accurate comparison of Medicare Part D and the FEHBP. The excluded classes comprised 16 drugs, including 1 antimigraine; 2 vitamins; 2 erectile dysfunction agents; 2 radiography agents; 1 central nervous system agent; 1 phosphate binder; 1 anti-Parkinson agent; 2 smoking-cessation drugs; 2 transplant agents; and 2 urinary tract antispasmodics.

only listed once. In addition, brand-name drugs with generic equivalents were added to the list. This means that if a brand-name drug was not listed on the formulary but its generic equivalent was, that drug was considered to be listed on the formulary. This process yielded a final

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list of 266 drugs (ie, 134 duplicated drugs were deleted), representing a total of 23 therapeutic classes. This list was further verified through literature review to ensure that these drugs represented at least 75% of all Medicare expenditures (Figure).26-29

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edicare Part D and the FEHBP Formulary Coverage: Table 4 M Brand versus Generic Drugs Brand/generic drug

Medicare Part D: FEHBP: 19 formularies 5 formularies (mean ± SD) (mean ± SD) P value

Brand-name drugs covered, %

82 ± 8.00

93 ± 8.02

.015

Generic drugs covered, %

90 ± 1.34

98 ± 1.10

.000

FEHBP indicates Federal Employees Health Benefits Program; SD, standard deviation.

Statistical Analysis The data were entered into the Statistical Product and Service Solutions 17.0, and an independent samples t-test was utilized to determine whether there were significant differences between Medicare Part D and the FEHBP prescription drug plans regarding the proportion of drugs covered, the proportion of brand-name or generic drugs covered, therapeutic classes, copay, and coinsurance. Copay was defined as the dollar amount that enrollees pay for prescription drugs, and coinsurance was defined as the percentage that enrollees pay for drugs. A negative binomial regression analysis was also performed to address the possibility that there were other variables that might have affected the difference between the 2 programs. For the regression analysis, the dependent variable was the number of drugs per therapeutic class, and the independent variables were type of plan (Medicare Part D or FEHBP), premium, copay, coinsurance, tier, enrollment, and therapeutic class. Results Overall, for the 19 Medicare Part D formularies that were analyzed (with 232 plans), formulary coverage of the top drugs dispensed and sold in the United States ranged from 72% to 94%; the range was 85% to 99% for the 5 FEHBP formularies (and 5 plans) that were examined (Table 2). On average, Medicare Part D plans covered 84% of the top drugs dispensed and sold in the United States compared with approximately 94% of the top drugs covered by the FEHBP plans (P <.05). For example, for the AARP MedicareRx Preferred prescription drug formulary, which represents the Part D formulary with the highest enrollment, 249 of the 266 (94%) top drugs were covered. By contrast, in the FEHBP formulary with the highest enrollment—Blue Cross and Blue Shield Service Benefit Plan Standard option—252 of the 266 (95%) top drugs were on the formulary. For formularies representing the least amount of enrollees (approximately

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80,000 beneficiaries each), Medicare Part D’s BravoRx formulary and the FEHBP’s American Postal Workers Union formulary, the percentages of drugs covered were 80% and 99%, respectively. Examination by therapeutic class showed that the average percentage of drugs covered per therapeutic class ranged from 0% to 100% for Medicare Part D formularies and from 52% to 100% for the FEHBP formularies (Table 3). The anxiolytics therapeutic class showed the greatest difference in drug coverage between formularies; among Medicare Part D formularies, none of the drugs was covered in this class, whereas the FEHBP formularies covered, on average, 95% of these drugs. In contrast, for some therapeutic classes, the average percentage of drugs covered was the same for Medicare Part D and for the FEHBP. For example, the top drugs in the anticonvulsant and antiretroviral/antiviral agent therapeutic classes were completely covered by Medicare Part D plans and the FEHBP plans. Of the 23 therapeutic classes analyzed in this study, Medicare Part D plans and the FEHBP plans covered at least 1 drug in each class, with the exception of the anxiolytics class. Analyses using the independent samples t-test revealed significant differences in drug coverage for the following 12 of the 23 therapeutic classes—attentiondeficit/hyperactivity disorder (ADHD) agents; an xiolytics; arthritis agents; blood glucose regulators; blood products, modifiers, volume expanders; cardiovascular (CV) agents; gastrointestinal (GI) agents; hormonal agents; metabolic bone disease agents; multiple sclerosis agents; ophthalmic agents; and respiratory tract agents (Table 3). In all of these therapeutic classes, the FEHBP was shown to provide broader drug coverage (P <.05). Table 4 shows how drug coverage differed by branded versus generic status. On average, the FEHBP plans covered approximately 98% of all generic drugs (among generic drugs only) versus approximately 90% for Medicare Part D plans. Similarly, Medicare Part D plans covered, on average, 82% of brand-name drugs (among brandname drugs only) compared with an average of 93% in the FEHBP plans (P <.05). The results of the negative binomial regression for the overall model showed that enrollment was the single strongest predictor of the number of drugs per therapeutic class. As enrollment increased, the number of drugs per therapeutic class increased. Furthermore, the number of drugs per therapeutic class was greater for tier 2 brand-name drugs compared with tier 1 generic drugs. The coefficients of copayment, coinsurance, and premium were not statistically significant (Table 5). For the anxiolytics therapeutic class, the FEHBP plans provided more drugs and other factors held constant. In addition, the respiratory tract agents therapeu-

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edicare Part D and the FEHBP Predictors of the Number of Drugs Covered in the Top 15 US Table 5 M Therapeutic Classes Type of plan (Medicare Part D or the FEHBP)

Premium

Copay

Coinsurance

Tier

Enrollment

ADHD agents

–.078

–.450E-03

.031a

1.704a

–1.849a

.050

Analgesics

–.025

–.243E-03

–.109E-02

.139

.015

.196E-02

Antibacterials

.033

.413E-03

.128E-02

.041

–.014

.016

Anticancer agents

.822E-02

.202E-03

.723E-02a

.513a

–.085a

.045a

Anticonvulsants

–.152E-28

.162E-31

–.372E-30

–.336E-28

.456E-29

–.26E-02

Antidepressants

.011

.645E-04

.372E-03

–.029

.443E-02

.172E-02

Antipsychotics

.020

.313E-03

–.273E-02

–.471

.040

–.24E-02

–2.06a

.387E-03

–.105E-02

-.174

.016

.422E-02

Arthritis agents

–.763E-02

.188E-03

.342E-02

.153

–.038

.022

Blood glucose

.564E-02

.942E-04

.123E-02

.193

–.018

.019

Blood products

–.020

.625E-03

–.110E-02

–.214

.017

.043a

Cardiovascular

–.018

.125E-03

–.342E-03

–.170

.838E-02

.022a

Gastrointestinal

–.052

.168E-03

–.192E-02

–.544

.035

.043a

Hormonal agents

–.041

.143-03

–.174E-03

–.305

.011

.025

Respiratory tract agents

–.067a

–.108E-03

–.168E-02

–.497a

.031

.028a

Drug class

Anxiolytics

Variable is significant at .05 confidence level. NOTE: This table summarizes the results for separate regressions by therapeutic class. For the variable type of plan, no significant difference was found between the classes for the number of drugs covered, except for anxiolytic and respiratory drugs. But the variable enrollment was positively associated with the number of drugs covered per therapeutic class for anticancer drugs, blood products, cardiovascular drugs, gastrointestinal drugs, and respiratory tract drugs. Coinsurance was a significant predictor of the number of drugs covered per therapeutic class for the ADHD, anticancer, and respiratory tract drug classes. Copay and tier were only significant for the ADHD and anticancer classes. ADHD indicates attention-deficit/hyperactivity disorder; FEHBP, Federal Employees Health Benefits Program.

tic class was borderline significant (P = .067) in favor of the FEHBP providing greater coverage. The remaining therapeutic classes (ie, ADHD agents, analgesics, antibacterial agents, anticancer agents, anticonvulsants, antidepressants, antipsychotics, arthritis agents, blood glucose regulators, CV agents, GI agents, and hormonal agents) showed no difference in drug coverage among plans when controlling for enrollment, premium, tier, coinsurance, and copayment. When comparing plans based on whether they provided cost-sharing through copayments versus coinsurance, results showed that Medicare Part D plans and the FEHBP plans utilized fixed-dollar copayments more often than coinsurance for tier 1 generic drugs. By contrast, for tier 2 brand-name drugs, Medicare Part D plans were more likely to utilize copays, whereas the FEHBP

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plans were more likely to utilize coinsurance. For the Medicare Part D plans, the mean copayment for tier 1 generic drugs was $4.53 (range, $0-$8) compared with a mean of $7.67 for the FEHBP plans (range, $5-$10; P <.05). The difference in tier 2 brand-name drugs coverage was nonsignificant (P = .901). The mean rate for Medicare Part D plans that utilized coinsurance for tier 1 generic drugs was 17% compared with a mean of 20% for the FEHBP plans (P <.01). For the Medicare Part D plans that utilized coinsurance for tier 2 brandname drugs, the mean was 26% compared with a mean of 34% for the FEHBP plans (P = .066).

Discussion Medicare Part D and the FEHBP both provide services to millions of enrollees, yet they have different methods

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of operation. Medicare has been criticized for its lack of provision of services. For example, 9 of 10 Medicare enrollees purchase supplemental coverage.6 Some advocate for reforming Medicare to look more like the FEHBP, citing the FEHBP’s exemplary benefits, service, catastrophic limits, cost control, lack of fraud and abuse, and protection against interest group politics as advantages.7-9 Evidence has been lacking on the full comparison of these programs, particularly given the challenges faced by a growing elderly population in the United States. The findings from this study reveal significant differences between the 2 programs. Analyses by therapeutic class have shown that the anxiolytics therapeutic class, which was composed entirely of benzodiazepine drugs (ie, alprazolam, clonazepam, diazepam, and lorazepam), showed the greatest difference in drug coverage between formularies. Among Medicare Part D formularies, none of the drugs was covered in this class, whereas the FEHBP formularies covered, on average, 95% of them. This finding may be explained by the difference in enrollee population characteristics of the 2 programs (ie, the majority of Medicare beneficiaries are older vs the FEHBP, which includes working-age adults and those aged ≥65 years). For example, some experts suggest that anxiolytics are not recommended for use in the elderly,30 whereas others recommend their use, but only with caution.31

The decision of whether to provide coverage for anxiolytics may also be based on the associated side effects and the addictive properties of the drugs. By contrast, recent studies reveal that the exclusion of anxiolytics from formularies may decrease use, but it may not result in better patient outcomes, specifically a decrease in fracture risk. The decision of whether to provide coverage for an xiolytics may also be based on the associated side effects and the addictive properties of the drugs.21,32 By contrast, recent studies reveal that the exclusion of anxiolytics from formularies may decrease use, but it may not result in better patient outcomes, specifically a decrease in fracture risk.33,34 Considering the lack of consensus on the use of anxiolytics, the benefits of the provision or the lack of coverage of these agents remains unclear. Yang and colleagues suggest that future studies that examine anxiolytic use in Medicare beneficiaries should focus on age, sex, and racial or ethnic differences among beneficiaries.35

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To shed further light on the coverage of anxiolytics and other classes of drugs, separate regression analyses were conducted, with the dependent variable defined as each therapeutic class (Table 5). The only 2 classes that showed a significant difference with respect to the type of plan were the anxiolytic and respiratory drug classes, with the FEHBP providing broader drug coverage. This shows that comparison of the FEHBP and the Medicare Part D program is complex; that is, many factors should be considered for such a comparison. The independent variables used in these analyses (ie, premium, tier, enrollment, copay, coinsurance, and therapeutic class) had an effect on coverage differences between the 2 programs. In addition, it is clear that coverage may be broader for one program versus another, but such coverage generosity depends on the therapeutic class. Regulation and other factors could possibly affect the inclusion of drugs on a formulary. With regard to premium, no significant differences were found. A review of the literature revealed that premiums are heavily dependent on the degree of cost-sharing. Specifically, some authors note that deductibles have the greatest impact on premiums. Perhaps including deductibles in the regression analyses would have resulted in significant differences for the variable premium.36 A recent examination of health plans in New York showed that changes in deductibles and cost-sharing can result in premium reductions of 50% or more.36 Other studies have shown that, although copay and coinsurance are used to deter enrollees from seeking services, premiums do not directly affect the number of services that are utilized. Furthermore, studies show that savings via cost-sharing result in decreased premiums, but the extent of savings depends on the type and the amount of cost-sharing.36 Therefore, it is understandable that results in the present study regarding premiums were nonsignificant. Future research that considers deductibles and fluctuations in cost-sharing may yield more significant premium-related results. Although fluctuations in cost-sharing were not explored, copay and coinsurance were included in the regression model as factors associated with the number of drugs covered per therapeutic class. A positive association was found for the number of drugs covered per therapeutic class and the copay for the ADHD and anticancer drug classes. An increase in copay by $1 resulted in an increase in the number of drugs covered in these classes. In addition, coinsurance was a significant predictor of the number of drugs covered per therapeutic class for ADHD, anticancer, and respiratory tract drugs. The number of ADHD and anticancer drugs rose as coinsur-

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ance increased; yet, the number of respiratory covered drugs decreased as coinsurance increased. This study shows that the relevance of individual therapeutic classes should be considered in the interpretation of cost-sharing findings. In a study by Avalere Health and the American Cancer Society Cancer Action Network that examined Medicare Part D plan cost-sharing for cancer drugs, it was noted that most Medicare plans place cancer drugs on higher tiers and that the coinsurance maximum is 33%.37 Earlier results of the regression analysis revealed that an increase in copay by $1 resulted in an increase in the number of anticancer agents. Therefore, both enrollees and plans can benefit from this type of benefit structure. Beneficiaries pay more through higher copays and coinsurance, yet they receive more drugs as a result. Similarly, plans provide more drugs, yet beneficiaries use less.38 For the variable tier, a significant difference was found for the ADHD agent and anticancer agent classes. For both classes, the number of drugs per therapeutic class was greater for tier 2 brand-name drugs compared with tier 1 generic drugs. It is interesting that more brand-name drugs were listed on the formularies than generic drugs, considering that generic drug promotion is often used as a cost-containment measure.39 Finally, variable enrollment was included in the regression analyses as a factor that would greatly affect the number of drugs per therapeutic class. For the initial overall model, enrollment was the single strongest predictor of the number of drugs per therapeutic class. As enrollment increased, the number of drugs per therapeutic class grew. Specifically, an increase was shown in the anticancer agents; blood products, modifiers, volume expanders; CV agents; GI agents; and respiratory tract agents classes. Both FEHBP and Medicare Part D plans offer an open enrollment season to beneficiaries. In 2009, Walton Francis commented that Medicare Part Dâ&#x20AC;&#x2122;s offering of an open enrollment season was a direct result of learning a lesson from the FEHBP.6 The FEHBP and Medicare Part D allow beneficiaries to disenroll in their current plan and to change to another plan once annually between November and December. During that period, if enrollees dislike their plan for any reason, they can choose another plan without penalty. Results of the regression analysis revealed that for 5 therapeutic classes, enrollment was positive and statistically significant. Therefore, for these classes, as enrollment increased by 1 person, the number of drugs offered in these classes increased. This finding becomes especially important during the discussion when prescription drug plan decision makers are trying to find ways to redesign themselves for improvement. For example, from

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this finding, we can learn that as Medicare seeks to determine ways to contain costs, the best time to examine drug coverage is after the open enrollment season.

Few studies have examined the FEHBP or Medicare Part D coverage of therapeutic drug classes. More up-to-date studies are needed related to access to anticancer drugs and to Medicare coverage to address the current debate on whether Medicare provides sufficient coverage for anticancer drugs. Furthermore, plans may find that after the open enrollment season, it is the best time to negotiate drug coverage with manufacturers. Plans can also tell enrollees that the list of drugs offered when they join will only increase after enrollment. The enrollees can benefit by knowing that the drugs in the anticancer agent; blood products, modifiers, volume expanders; CV agent; GI agent; and respiratory tract agent therapeutic classes will only increase in number after they join. Studies show that the number of enrollees opting to change plans is very low for the FEHBP.6 Some have stated that this is a result of enrollee brand loyalty and older age. Few studies have examined the FEHBP or Medicare Part D coverage of therapeutic drug classes. Bowman and colleagues examined formulary coverage in Medicare Part D plans for anticancer drugs, showing that the majority of cancer drugs were covered by almost all Medicare Part D plans.40 More up-to-date studies are needed related to access to anticancer drugs and to Medicare coverage to address the current debate on whether Medicare provides sufficient coverage for anticancer drugs. Gellad and colleagues examined Medicare Part D plan coverage of angiotensin receptor blockers (ARBs), which are categorized under the CV agent class.41 Results showed that all Medicare Part D prescription drug plan formularies included at least 1 ARB, and 35% of the plans covered all 7 ARBs discussed in the study.41 Consistent with previous research, our study also shows that Medicare Part D plans cover a large number of anticancer and CV drugs. Tseng and colleagues reported on Medicare Part D plan coverage related to GI drugs, CV drugs, respiratory agents, antidepressants, blood glucose regulators, and analgesic classes; their findings reveal that the greatest coverage (85%-90% of Part D plans) was for CV agents.39 However, the authors

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concluded that less than 50% of the drugs examined (34 of 75) were widely covered by Medicare Part D plans.39 Although mostly found in published reports, broad coverage of formulary drugs has also been shown within therapeutic classes in the FEHBP. A 2003 US Government Accountability Office (GAO) report shows that FEHBP enrollees generally have unrestricted access to prescription drugs.42 Furthermore, formularies are not considered to be overly restrictive, based on the study’s findings on most major therapeutic drug categories.42 As for coverage of brand versus generic drugs, a 2007 study by the Lewin Group reveals that Medicare Part D plans covered more of the 132 benchmark brand-name drugs (128, or 97%) compared with the FEHBP (125, or 95%).43 However, the researchers did not conduct any statistical analyses43; therefore, it is impossible to determine any significant difference between the 2 groups. Tseng and colleagues found that Medicare Part D plans covered 90% of generic drugs, but they did not examine the FEHBP.39 The reason that a drug is included on a formulary can be complex. A 2010 GAO report on specialty drugs for the FEHBP and Medicare Part D examined the reasons why some drugs were included on the formulary and why others were not.44 The findings revealed that Medicare Part D plans considered limited ability to negotiate price concessions with manufacturers, low utilization for some drugs, and CMS’s US Pharmacopeia–guided formulary requirements were barriers to inclusion of drugs on formulary.44 The conclusions drawn from this report are noted with caution, given the unique nature and different set of issues surrounding specialty drugs. Overall, the findings of the bivariate analysis in this present study revealed that the FEHBP provided broader drug coverage than the Medicare Part D program. Some of the results of the bivariate analysis disappeared in multivariate analysis, revealing only a small difference between the 2 programs and one that only persisted within specific therapeutic classes. This difference in findings using the 2 different analytical methods may be useful to various groups. For example, consumers may be interested in the actual number and the kind of drugs on their formulary, so they may find the t-test results useful. Other consumers may find copay and coinsurance to be important and may focus on regression results. Health plan providers may be more interested in how factors such as premium, copay, coinsurance, tier, and enrollment affect drug coverage as they make complex decisions on which drugs to include on their formulary.

Limitations Several limitations should be considered in interpret-

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ing the findings of this research. First, data were not available on the demographics of enrollees within each plan. Although factors such as age, income, sex, race, and employment status may affect the results, only the largest plans were used in this study, and clinical needs can be extrapolated from general populations. Second, caution should be used in the interpretation of results that come from the cross-sectional nature of the data. Plans are subject to change over time. The data used in this research represent coverage in the year 2009. Therefore, these data may not capture the full impact of drug coverage in 2013. Third, not all Medicare Part D and FEHBP plans were included in the study. Nevertheless, the analyses included the top 63% prescription drug plans in Medicare Part D and 70% of those in the FEHBP. This represents a considerable increase from previous studies, which only compared a maximum of 3 Medicare Part D and FEHBP prescription drug plans.40,43,45

Conclusion By the year 2030, the United States is expected to have 71 million persons aged ≥65 years.46 For the first time in history, the United States may have more elderly individuals than working individuals. Many projections indicate that Medicare will not be able to deliver promised benefits to the next generation of retirees without making changes to the program.10 Policymakers and healthcare professionals are interested in recommendations to address the anticipated needs of older persons. To avoid extreme increases in payroll taxes and other revenues or major cutbacks in services, Medicare must explore ways to change the healthcare system to achieve better value for the money. The experience of the FEHBP suggests a possible means of accomplishing this objective. There are lessons here to be gleaned for both Medicare Part D and the FEHBP. Important areas for future research in the comparison of these 2 programs are the role of demographic factors in prescription drug coverage, the market behavior of prescription drug plans, the impact of increasing oral drugs for classes once administered parenterally (hence reduced costs), and health outcomes associated with drug coverage. n Acknowledgment The author would like to thank Dr Ronald Ward for his invaluable support and review of this manuscript. Study Funding This study was supported by funding from the PhRMA Foundation through a predoctoral fellowship in health outcomes.

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Author Disclosure Statement Dr Lovett has no conflicts of interest to report.

References

1. Centers for Medicare & Medicaid Services. Office of the Actuary. National Health Statistics Group. National Health Care Expenditures Data. www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/National HealthExpendData/downloads/tables.pdf. Accessed January 28, 2013. 2. Centers for Medicare & Medicaid Services. Office of the Actuary. National Health Statistics Group. www.cms.gov/Research-Statistics-Data-and-Systems/StatisticsTrends-and-Reports/NationalHealthExpendData/NationalHealthAccounts Historical.html. Accessed January 22, 2013. 3. 2010 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Washington, DC; August 5, 2010. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/ReportsTrustFunds/downloads/tr2010.pdf. Accessed January 13, 2013. 4. Henry J. Kaiser Family Foundation. Medicare chartpack: overview of Medicare Part D organizations, plans, and benefits by enrollment in 2006 and 2007. November 2007. www.kff.org/medicare/upload/7710.pdf. Accessed January 30, 2013. 5. 2009 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Fund. Washington, DC; May 12, 2009. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trendsand-Reports/ReportsTrustFunds/downloads/tr2009.pdf. Accessed January 28, 2013. 6. Francis W. Putting Medicare Consumers in Charge: Lessons from the FEHBP. 1st ed. Washington, DC: American Enterprise Institute Press; 2009. 7. National Bipartisan Commission on the Future of Medicare. Building a better Medicare for today and tomorrow. March 16, 1999. http://medicare.commission.gov/ medicare/bbmtt31599.html. Accessed June 5, 2009. 8. Francis W. Using the federal employees’ model: nine tests for rational Medicare reform. 2003. www.heritage.org/Research/Reports/2003/08/Using-the-Federal-EmployeesModel-Nine-Tests-for-Rational-Medicare-Reform. Accessed January 9, 2009. 9. Oberlander J. Through the looking glass: the politics of the Medicare Prescrip tion Drug, Improvement, and Modernization Act. J Health Politics Policy Law. 2007; 32:187-219. 10. Butler SM, Moffit RE. The FEHBP as a model for a new Medicare program. Health Aff (Millwood). 1995;14:47-61. 11. Francis W. The FEHBP as a model for Medicare reform: separating fact from fiction. August 7, 2003. www.heritage.org/Research/Reports/2003/08/The-FEHBP-as-aModel-for-Medicare-Reform-Separating-Fact-from-Fiction. Accessed January 9, 2009. 12. Hoff J. Medicare Private Contracting: Paternalism or Autonomy? Washington, DC: American Enterprise Institute Press; 1998. 13. McBride T, Andrews C, Mueller K, Shambaugh-Miller M. An analysis of availability of Medicare+Choice, commercial HMO, and FEHBP plans in rural areas: implications for Medicare reform. Rural Policy Brief. 2003;8:1-8. www.unmc.edu/ ruprihealth/Pubs/PB2003-5.pdf. Accessed December 5, 2008. 14. Francis W. The political economy of the Federal Employees Health Benefits Program. In Helms RB. Health Policy Reform: Competition and Controls. 1st ed. Washington, DC: American Enterprise Institute Press; 1993:269-303. 15. Peck B. Private Insurance Plans and Medicare: the Disappointing History. Public Citizen’s Congress Watch; 2003. www.citizen.org/documents/privatemedicare.pdf. Accessed January 28, 2013. 16. Moon M. Medicare, Modernization and FEHBP. March 20, 2002. www.urban. org/publications/900489.html. Accessed May 7, 2009. 17. Oberlander J. Is premium support the right medicine for Medicare? Health Aff (Millwood). 2000;19:84-99. 18. D’Angelo G, Moffit RE. Time to get serious (again) about Medicare reform. May 13, 2009. www.heritage.org/research/reports/2009/05/time-to-get-serious-again-aboutmedicare-reform#_ftn1. Accessed July 9, 2010. 19. Cubanski J, Neuman P. Status report on Medicare Part D enrollment in 2006: analysis of plan-specific market share and coverage. Health Aff (Millwood). 2007;26:w1-w12. 20. Hoadley J, Hargrave E, Cubanski J, Neuman T. The Medicare Drug Benefit. An in-depth examination of formularies and other features of Medicare drug plans. Kaiser Family Foundation. 2006. www.kff.org/medicare/upload/7489.pdf. Accessed January 30, 2013. 21. United States Pharmacopeial Convention. Medicare prescription drug benefit: summary of USP approach and methodology to the model guidelines version 4.0: drug categories and classes in Part D. February 4, 2008. www.usp.org/sites/default/ files/usp_pdf/EN/healthcareProfessionals/modelguidelinesv4summaryofapproach.pdf. Accessed January 29, 2013. 22. CVS Caremark. Blue Cross Blue Shield formulary: basic and standard versions. www.caremark.com/portal/asset/feprx_drug_list48.pdf. Accessed January 29, 2013.

23. Medco Health. 2012 Formulary Reference Guide. https://host1.medcohealth. com/art/corporate/medco_formularies.pdf. Accessed January 29, 2013. 24. NALC Health Benefit Plan Formulary. January 2013. www.nalc.org/depart/hbp/ news/Forms/Caremark/DrugList.pdf. Accessed January 29, 2013. 25. Bartholow M. Top 200 prescription drugs of 2009. Pharmacy Times. www.pharmacy times.com/publications/issue/2010/May2010/RxFocusTopDrugs-0510. Accessed January 5, 2010. 26. Soni A. The top five therapeutic classes of outpatient prescription drugs ranked by total expense for adults age 18 and older in the U.S. civilian noninstitutionalized population, 2006. Statistical Brief #232. 2009. www.meps.ahrq.gov/mepsweb/data_ files/publications/st232/stat232.pdf. Accessed March 11, 2009. 27. Stevenson DG, Huskamp HA, Keating NL, et al. Medicare Part D and nursing home residents. J Am Geriatr Soc. 2007;55:1115-1125. 28. Simoni-Wastila L, Shaffer T, Stuart B. A national comparison of prescription drug expenditures by Medicare beneficiaries living in the community and long-term care facility settings. February 15, 2007. http://aspe.hhs.gov/daltcp/reports/2007/ pdnatcom.pdf. Accessed March 8, 2009. 29. Families USA. Enough to make you sick: prescription drug prices for the elderly. June 2001. Publication No. 01-103. http://familiesusa2.org/assets/pdfs/Enough-toMake-You-Sick.pdf. Accessed March 11, 2009. 30. Pontillo DC, Lang AJ, Stein MB. Management and treatment of anxiety disorders in the older patient. Clin Geriatr. 2002;10:38-49. 31. Merck Manual of Geriatrics. Generalized anxiety disorder. 2010. www.merck manuals.com/professional/psychiatric_disorders/anxiety_disorders/generalized_ anxiety_disorder.html. Accessed August 6, 2010. 32. Bambauer KZ, Sabin JE, Soumerai SB. The exclusion of benzodiazepine coverage in Medicare: simple steps for avoiding a public health crisis. Psychiatr Serv. 2005;56: 1143-1146. 33. Briesacher BA, Soumerai SB, Field TS, et al. Medicare Part D’s exclusion of benzodiazepines and fracture risk in nursing homes. Arch Intern Med. 2010;170:693-698. 34. Wagner AK, Ross-Degnan D, Gurwitz JH, et al. Effect of New York State regulatory action on benzodiazepine prescribing and hip fracture rates. Ann Intern Med. 2007; 146:96-103. 35. Yang HW, Simoni-Wastila L, Zuckerman IH, Stuart B. Benzodiazepine use and expenditures for Medicare beneficiaries and the implications of Medicare Part D exclusions. Psychiatr Serv. 2008;59:384-391. 36. Gorman B, Gorman D, Newell P; United Hospital Fund. Cost sharing in New York’s health insurance market. 2010. http://uhfnyc.org/assets/795. Accessed January 30, 2013. 37. Murphy L, Sadownick S, Ford C, et al. Cost sharing for cancer patients in Medicare, 2009. December 2008. www.avalerehealth.net/research/docs/ACS_CAN_ Cost_Sharing_Analysis.pdf. Accessed January 30, 2013. 38. Huskamp HA, Deverka PA, Epstein AM, et al. The effect of incentive-based formularies on prescription-drug utilization and spending. N Engl J Med. 2003;349: 2224-2232. 39. Tseng CW, Mangione CM, Brook RH, et al. Identifying widely covered drugs and drug coverage variation among Medicare Part D formularies. JAMA. 2007;297: 2596-2602. 40. Bowman J, Rousseau A, Silk D, Harrison C. Access to cancer drugs in Medicare Part D: formulary placement and beneficiary cost sharing in 2006. Health Aff (Millwood). 2006;25:1240-1248. 41. Gellad WF, Huskamp HA, Phillips KA, et al. Angiotensin receptor blockers on the formularies of Medicare drug plans. J Gen Intern Med. 2007;22:1172-1175. 42. US Government Accountability Office. Federal Employees’ Health Benefits: effects of using pharmacy benefit managers on health plans, enrollees, and pharmacies. January 2003. GAO-03-196. www.gao.gov/new.items/d03196.pdf. Accessed January 28, 2013. 43. The Lewin Group, Inc. Comparison of VA national formulary and formularies of the highest enrollment plans in Medicare Part D and the Federal Employee Health Benefit Program. December 2008 (data compiled in 2007). www.lewin.com/~/media/ Lewin/Site_Sections/Publications/3987.pdf. Accessed January 28, 2013. 44. US Government Accountability Office. Medicare Part D: spending, beneficiary cost sharing, and cost-containment efforts for high-cost drugs eligible for a specialty tier. January 2010. GAO-10-242. www.gao.gov/new.items/d10242.pdf. Accessed January 28, 2013. 45. Yamamoto D, Neuman T, Strollo MK. How does the benefit value of Medicare compare to the benefit value of typical large employer plans? The Henry J. Kaiser Family Foundation; 2008; Publication #7768. www.kff.org/medicare/upload/7768.pdf. Accessed January 28, 2013. 46. Centers for Disease Control and Prevention, Merck Company Foundation. The state of aging and health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation; 2007. www.cdc.gov/aging/pdf/saha_2007.pdf. Accessed June 8, 2009.

Stakeholder perspective on page 58

Vol 6, No 1

January/February 2013

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American Health & Drug Benefits

REGULATORY

Stakeholder Perspective

Medicare Part D and the Federal Employees Health Benefits Program By J. Warren Salmon, PhD Professor of Health Policy and Administration, School of Public Health, University of Illinois at Chicago

POLICYMAKERS: Policy analyses of in-place federal programs tend to wane over time, and it seems that ongoing policymaking often fails to sufficiently regard historical precedents. At first, interest is high and some funding may be available for research, but, even when they are known to be “successful,” programs are often not explored to extract key learning, as we may likely see with aspects of the Affordable Care Act (ACA). Reflective policymaking that is based on health services research is most important in today’s healthcare system. In this article on Medicare Part D and the Federal Employees Health Benefits Program (FEHBP) comparison of prescription drug coverage, Dr Lovett probes drug coverage issues and attempts to examine cost-sharing. By design, both programs rely on the marketplace with loose overarching regulatory structures. Over the years, the FEHBP has been known to be cost-saving for quality care, with high employee acceptance. Its functionality, nevertheless, extends beyond mere drug policies, because of the similar character of its participating plans that bid for contracts. Medicare Part D plans share a heterogeneity, and it has taken a few years to become ready for health services research to assess the program’s effectiveness and patient outcomes. HEALTH PLANS/Researchers: This article by Dr Lovett nicely highlights the programmatic differences in plan coverage, enrollment, premiums, copayments and coinsurance, tiers, and therapeutic classes. Yet, we should be mindful that the served populations differ dramatically (families of federal employees vs the much more vulnerable aged and disabled). Further clinical studies on benefit design would serve to capture what works best in the ongoing marketplace tinkering with

American Health & Drug Benefits

drug benefits that private and public payers are pursuing. Such a direction may yield wisdom in formulating better policies for health insurance exchanges. Accountable care organizations (ACOs) could become experimental laboratories to test benefit designs for differing populations across the United States and across disease states. Pharmacy and Therapeutic Committees may be natural settings for initiating studies to address puzzling cost and care issues within formularies. Evidence-based investigations should be aimed at being relevant to ongoing public policy implementation. It must be noted that the FEHBP provides more than an insurance mechanism; it is embedded within delivery of care systems, as hopes for the ACOs are also intended. Medicare Part D and the new drug benefit designs under the ACA, along with Medicaid programs, should be carefully scrutinized and critiqued as our nation more diligently embarks on the implementation of health reform. Organized systems of care delivery have proved to be superior for population-based health, as better Medicare Advantage plans can demonstrate in learning from practice. The FEHBP may be a possible model for addressing some drug coverage for savings in Medicare, but these 2 government programs are both complex and still differ greatly. The study’s focus on varying uses in drug classifications and coverage point to the need for more detailed analyses in such investigations. Although issues remain on the suitability of FEHBPtype approaches (eg, a more costly vulnerable patient group) for Medicare reform, this study goes a long way to demonstrate that prudent means of reorganizing care through health services research are superior to political fiat for cost-cutting. n

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Ever feel as if the costs of diabetes management just keep coming around?

Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed.1 One issue is medication adherence.2 Medication adherence may prevent hospitalizations for diabetes complications.2 Another major issue is hypoglycemia. Not only is it a barrier to successful diabetes management,1 but it can also be very costly3: • ER-to-inpatient costs: $10,3623 • ER plus outpatient costs: $9863 • Hospital admission costs: $7,3173

However, you may not be informed of all your members’ hypoglycemic events. In a multicenter, retrospective medical record review of 3 academic emergency departments, 83% of hypoglycemia visits, often excluded in prior hypoglycemia analyses, were coded as “diabetes with other specified manifestations,” while others may not be reported at all.4 For these reasons, diabetes management costs may be even greater than you know.

That’s why Novo Nordisk is committed to providing your organization with a broad range of solutions in glycemic management. For more information about Novo Nordisk, please visit novonordisk-us.com. References: 1. American Diabetes Association®. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63. 2. Healthcare Cost and Utilization Project. Economic and Health Costs of Diabetes. Rockville, MD: Agency for Healthcare Research and Quality; 2005. 3. Curkendall SM, Zhang B, Oh KS, Williams SA, Pollack MF, Graham J. Incidence and cost of hypoglycemia among patients with type 2 diabetes in the United States: analysis of a health insurance database. JCOM. 2011;18(10):455-462. 4. Ginde AA, Blanc PG, Lieberman RM, Camargo CA Jr. Validation of ICD-9-CM coding algorithm for improved identification of hypoglycemia visits. BMC Endocr Disord [series online]. April 1, 2008;doc 8:4.

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