Employers and consumers are looking for new solutions to the healthcare challenges being faced today, including the complexity of benefits, gaps in care and rising costs. That mindset has caused leading payers to think outside the box in their attempt to win new customers.

A sound strategy built around innovation and customer care is winning out as payers try to ensure that not only do they keep the customers they have, but bring in new ones to achieve success.

, which serves more than 40 health plans across the U.S., says regardless of the product segment, any payer’s success depends largely on its ability to 

“Few payers have mastered consumer engagement-historically, they haven’t had to,” he says. “But with the growth of consumerism in healthcare and the shift to value-based care, building meaningful connections with consumers has become imperative.”

Therefore, to remain competitive, he says, health plans need to take a page from leading consumer brands and adopt the consumer engagement best practices they have already perfected, including user segmentation and propensity analytics, personalized content and communication channels, and rewards that not only inspire action but build long-term trust with members.

Christine Paige, chief marketing executive of Kaiser Permanente, an integrated managed care consortium based in Oakland, California, says one of the biggest changes over the years is the move toward greater personalization.

“There’s been an increased usage of what people have told us about their interests and preferences to make the information and dialogue more relevant,” she says. “That is different from the one-size-fits-all communication that used to prevail.”

Nick Brecker, president, specialty business for Anthem Blue Cross Blue Shield, an Indianapolis-based health insurance company, says the company’s strategy focuses on offering leading products combined with an industry-leading approach to “whole person healthcare.”

“While our specialty products (dental, vision, life and disability, and voluntary supplemental health plans) are available on a stand-alone basis, they can be packaged with our health plan products to better coordinate care, which results in more efficiencies, better health outcomes and bigger savings,” he said. “This is made possible by Anthem Whole Health Connection. This unique approach to a person’s whole health connects claims and clinical data to identify and impact gaps in care, lowers costs, and delivers a simpler healthcare experience to our consumers.”

He notes healthcare is inherently personal and Anthem Blue Cross Blue Shield’s (Anthem) Specialty business is focused on helping to make the delivery of healthcare as personalized and tailored as possible for every consumer.

“Our integrated approach to ‘whole person healthcare’ means we have the opportunity to help our consumers better manage their health conditions through early intervention and by closing gaps in their care,” he says.

John Nicolaou, a healthcare payer expert at 

, says payers need to acquire customers from their competitors in order to grow organically.

“The biggest focus we are seeing is on brand and service differentiation rather than product or benefit differentiation,” he says. “An example would be tools to help predict out-of-pocket payments, or to encourage and reward healthy lifestyle behaviors to help members manage their health costs.”

There are also similar avenues for employers to better manage the cost of care, including improved claim analytics or to reward healthier behaviors.

Why Consumer Engagement Must Be a Whole-Person Solution

“It will be critical to make these brand and service differentiations attractive and relevant and valuable for members, rather than gimmicks for payers,” Nicolaou says. “Key to this is to understand not just who their members are, but rather to understand their member relationships with payers and the health system overall to find ways to differentiate.”

, a healthcare payment network in Walnut Creek, California, says payers need to focus on improving the member experience and look at the consumer experience in other industries to understand the benchmarks.

Trends in Healthcare Payments Ninth Annual Report

, 86% of consumers want to make all of their healthcare payments in one place,” he says. “Payers can help consumers meet this need by offering payment capabilities within their member portals. Payers can take the friction out of healthcare payments and increase member satisfaction, increase member portal traffic and tool utilization, and accelerate payments to providers from members.”

, says payers leverage the CarePort care coordination platform to drive financial and quality outcomes.

She explains specific opportunities for payers to leverage CarePort include: guiding members to the most appropriate level of care, enabling ED diversion, tracking patients in real time to power effective transitions of care, and increasing first submission success around post-acute authorizations.

“CarePort’s vast provider footprint enables payers to most effectively and efficiently achieve visibility into member utilization and progression across settings of care, helping to drive better quality and cost outcomes and patient experiences,” Hu says. “Nearly 1,000 hospitals and more than 20,000 post-acute providers use our platform for comprehensive care transition work flows including utilization management, discharge planning, care coordination, tracking outcomes, and refining work flows.”

Stewart Schaffer, co-founder and managing partner of 

, a Tampa, Florida-based healthcare advisory firm, notes employers very much want to work directly with healthcare systems to provide healthcare coverage for their employees and healthcare systems also want to work directly with employers to do the same.

“Both parties already know the many potential advantages of working face-to-face with each other so the market is prime for direct-to-employer group health plans,” he says. “All that is missing is the infrastructure, technology, and expertise to make it all happen. Our sales and marketing strategy is simply to tell the story of how the combined expertise and experience of CSuite Solutions and KBA have partnered to make this all happen.”

With that in mind, when looking to add customers, CSuite Solutions focuses on risk management, plan designs, claims processing, open enrollments, case management, care coordination, proactive health management, and overall customer service. 

“You have to take an enterprise approach to delivering these programs. This is not just a network contracting exercise. By this I mean that healthcare systems have to look at these programs like they would going into a new business that is quite different from what they do now,” Schaffer says. “The simple thought that having employers as customers is a whole new world for them has to be accepted throughout the organization. We understand and facilitate cultural acceptance of these programs across the enterprise so that successful outcomes can be assured.”

Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.

Articles

A look at what payers are-or should be-focusing on in terms of their strategy for getting customers.

Top Payer Growth Strategies

Each year there are more than 17,000 deaths nationally from prescription opioid overdoses, 

 that 75% of U.S. employers say their workplace has been directly affected by opioid usage but only 17% feel well prepared to deal with the issue.

In response to the local and national ongoing opioid epidemic, 

 (FCH), a provider-owned health benefits company, which serves over 1 million people in Washington and the Northwest, wanted to do its part to help.

Launched on July 11, 2019, FCH’s Workforce Prescription Opioid Use Report, is offered free of charge to employers in the Puget Sound area with over 200 employees until Sept 15, 2019. The report will help identify high rates of opioid use, which can be associated with potential misuse and addiction among employees.

Once initiated, the employer will instruct their pharmacy benefits manager (PBM) to send their pharmacy claims to FCH to be analyzed. This extracted information will be de-identified with no personal health information and is completely HIPAA-compliant.

The Impact of Preoperative Opioid Use on Patient Outcomes

 tackling opioid abuse in the workplace.

“We are constantly innovating our application of data to help create healthier workforces, while responding to our society’s most serious health concerns,” says John W. Robinson, MD, chief medical officer, FCH. “Opioids are at the top of that list. We are implementing this workforce prescription opioid use report as a community service to help employers recognize if they have an opioid problem in their workforce.” 

, which was established so that public and private healthcare stakeholders would have the opportunity to identify specific ways to improve healthcare quality, outcomes, and affordability in Washington State.

In 2017, the Bree Collaborative produced the 

. This screening report uses four of the nine opioid prescribing metrics developed by the Bree Collaborative, a workgroup convened in 2017 to help implement opioid guidelines and standardize comparisons between populations to help implement opioid guidelines and standardize comparisons between populations.

Actuarial consulting firm Milliman participated in this project by verifying the analytic code used to compute the results for the report. (The report results will be strictly workforce aggregate, and there will not be any individual employee results.)

Metric 1: Percentage of patients prescribed any opioid by age group

Metric 2: Percentage of patients prescribed chronic opioids (60 days of opioids in one quarter) 

Metric 3: Percentage of patients prescribed chronic opioids and sedatives together

Metric 4: Percentage of new member's day supply of first opioid prescription which are greater than 14 days

previously announced Case Management program

 tackling opioid misuse and abuse uses the nine opioid prescribing metrics developed by The Bree Collaborative. FCH is already providing its clients with a comprehensive population health report to identify potential risks, with one high-risk group including anyone who has been prescribed opioids together with sedatives for more than 60 days within a three-month period, a potentially deadly combination.

Once those at risk have been identified, FCH’s medical and behavioral health case managers will reach out to the employees and confidentially discuss their prescription use and treatment options, which may include alternative pain management or counseling. The entire program is confidential but gives employers more tools to help employees in need without specifically identifying them.

“This program is aimed at reducing opioid misuse and abuse in the workplace, which can affect productivity, absenteeism, health, and safety,” Robinson says.  “Following that launch, we started receiving inquiries from employers-who weren’t our clients-asking how they could get this report. That gave us the final push to launch this program in an effort to support our community. We created a simpler screening opioid use report that we could offer to community employers with at least 200 employees, which would only require pharmacy claims from the PBM. The results contain no employee names or identifying information.”

This model is applicable to any health plan or TPA, according to Robinson. To conduct this four-measure screening report on workforce prescription opioid use, FCH needs the health plan/TPA to provide a signed Data Use Agreement and the PBM to provide the de-identified pharmacy claims extract with just seven claim fields. 

While this is a program for the Seattle region, it’s a unique initiative that could provide a blueprint for other health care organizations aiming to tackle this problem throughout the country, according to Robinson.

“Depending on the response from the community, this program could be rolled out to other communities and other states,” he says.

The first step to addressing opioid abuse for employers is to identify potential misuse and addiction.

New Report is Tackling Workplace Opioid Abuse

Hospital executives face a myriad of challenges in today’s ever-changing healthcare landscape. 

 asked some chief executives what their biggest challenge has been, and how they have worked to overcome it. Here’s what they had to say.

Alex Hellinger, DPT, MBA, executive director, 

, New York, says his biggest challenge has been bringing healthcare back to a community that had recently lost a major hospital and lacked sufficient medical resources.

“When a hospital closes, the vast majority of health providers leave the area, ultimately creating a medical desert,” he says. “My team and I addressed the challenge by building a comprehensive medical network throughout downtown Manhattan in phases, initially opening Manhattan’s first free-standing emergency department and then gradually adding essential services including imaging, ambulatory surgery, orthopedic and rehabilitation programs, as well as primary and specialty care.”

Top 4 Challenges Healthcare Executives Face in 2019

When building a comprehensive medical center from scratch, Hellinger had to step back and take a fresh look from a patient’s perspective at how healthcare should be delivered. “We fulfilled this objective by implementing services such as telehealth, and a personalized website for physician referrals and home-based healthcare programs,” he says. “The center has positioned itself as a vital community resource by partnering with longstanding neighborhood organizations and offering free public services, such as immunizations and health screenings.”

, Edison, New Jersey, has found navigating two different payment models to be a big challenge. “We’re moving from a volume-based environment to a value-based environment,” he says. “Our 17 hospitals need to remain solvent, so we are still reimbursed on a fee-for-service basis to a large extent. If I had to pick a definitive path-to either stay in fee-for-service or go into the value-based world-I would vote for going into the value-based world. That’s because all the incentives are aligned and physicians and hospitals are rewarded for achieving the best outcomes for the people we serve.”

Garrett has found this to be the best strategy when looking to lower the overall cost of care delivery. “To keep the needle moving toward value, we are growing our accountable care organizations (ACOs),” he says, adding that the health system’s best performing ACO saved about $145 million over five years and is among the nation’s top performers. “Beyond ACOs, we are investing in more patient-centered models including bundled payments, shared risk arrangements, and value-based purchasing.”

Teaneck, New Jersey, which has 351 inpatient beds, has found it challenging to provide patients with high-quality, affordable care in a transparent, cost-effective manner in light of its small size.

“With individuals demanding to play a much more active role in choosing where and how they spend their healthcare dollars, we need to ensure that patients receive high-quality, patient-focused care,” Maron says. To provide this, Holy Name is moving away from a procedure-driven model toward a relationship-building model that is more patient-centric, focusing on every individual’s unique needs. These include linguistic, dietary, cultural, religious, familial, financial needs, as well as personal and social considerations. 

Holy Name’s outreach programs and culturally-sensitive initiatives such as Asian Health Services, Familia Y Salud, and its faith-based services have become national models for addressing the diverse needs of various populations. 

As the healthcare market continues to change, Holy Name will continue to work with policymakers, insurers, and other stakeholders to accomplish its goals.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.

Managed Healthcare Executive asked some chief executives what their biggest challenge has been, and how they have worked to overcome it. Here’s what they had to say.

Top 3 Issues for Hospital Executives

More and more, payers and providers are realizing the value of integrating patients’ social determinants of health (SDoH) data into patient care initiatives. With the industry looking toward a value-based care future, it’s becoming clear that finding ways to incorporate what the World Health Organization defines as “the conditions in which people are born, grow, live, work, and age” is vital to improved health outcomes-and a healthy society, in general.

This includes using SDoH data to help guide the development and implementation of successful population health strategies, says Ali H. Mokdad, PhD, chief strategy officer for population health at the University of Washington School of Medicine. He argues that healthcare professionals can develop excellent, evidence-based population health initiatives-but unless a particular population’s SDOHs are considered, such programs will not be as effective as desired.

“A patient’s environment plays a critical role on whether or not they can actively participate in their own health and wellness,” he explains. “If a family is struggling to pay their rent, they are not going to spend money on preventative care. If a family can’t find fresh fruits and vegetables that are affordable in their neighborhood, they won’t eat a healthy diet. If they are in a neighborhood that isn’t so safe, it may be hard for them to be physically active. It is very important that we address all of these aspects early on so we invest in the right kind of population health approaches-and don’t waste time and money with trial and error type programs.”

Dion Sheidy, a healthcare advisory leader with KMPG, a professional services firm, says that while adding SDoH data into population health initiatives seems like it should be a fairly simple thing to do, it’s much harder than one might expect in practice.

“The biggest challenge to using this information to help deliver care in an appropriate setting and an appropriate way is actually the data itself,” he explains. “Providers may not even collect this kind of information about a patient. If they do, the data exist in lots of different places and are saved in lots of different formats. The ability of any organization to successfully pull that data into a single location to help drive data-driven care is very difficult to do.”

, a leading healthcare payer organization, has made strides in incorporating SDoH into their population health strategies with their Bold Goal initiative, a unique program to help better care for patients with chronic medical conditions. Humana aims to improve the health of the communities they serve by 20% by 2020. Part of that strategy is considering SDoH factors like food insecurity and social isolation in their population health programs.

“We understand that food insecurity, social isolation, transportation security, and housing are all directly related to health,” says Andrew Renda, MD, MPH, associate vice president of population health at Humana. “This program allows us to bring those things into the mainstream of healthcare so we can start treating SDoH for what they are-clinical gaps in care.”

Caraline Coats, MHSA, vice president of Bold Goal and Population Health Strategy, says healthcare has been too medically focused for too long. “Today, as an industry, we only spend 4% of every healthcare dollar on social health. Everyone knows it’s important to health outcomes, particularly the clinicians. But we needed to find a way to provide the data and resources providers needed so they could treat social health factors too.”

It was a challenging undertaking. But Renda said they started by simply standardizing their SDoH data collection.

4 Ways Health Plans and Communities Can Address SDOH

“We needed to agree on common definitions and a way to codify those definitions,” he says. “For food insecurity, we decided to use the United States Department of Agriculture (USDA) Vital Signs screener, a two-question survey, and for social isolation and loneliness, we used a three-question scale from the University of California Los Angeles (UCLA) called the Loneliness Scale.”

By using these validated screeners, Humana was able to more effectively incorporate the data into their different well-being and direct clinical platforms. In 2018, the health plan screened 50,000 of their members in San Antonio, markets on these particular social determinants. And, in doing so, they were able to bring that information into their data ecosystems to not only help their providers make appropriate referrals to their patients for different resources, but also to assist Humana in their development of more effective population health programs.

After only a few years, Bold Goal is seeing clinical gains. The integration of SDoH information helped to increase the number of self-reported “healthy days” by Medicare Advantage members in Humana communities by 2.7 days. While 2.7 days might not seem like much, 

 beneficiaries in communities who did not participate in the Bold Goal program saw a decrease of 0.6 healthy days for the year. While Coats said Bold Goal program is still in its early stages, she is buoyed by the results so far.

“I firmly believe there is a return on both health and financial investment in social determinants,” she says. “We have incredible qualitative data and feedback from our members. It is going to take time to prove all this out but, with the space and time to prove the importance of social health on the overall quality of life, we will get there.”

Renda agrees. “We see that the program is moving in the right direction with both the healthy days numbers as well as other improvements we’ve seen in physical and mental health in our members,” he says. “We see SDoH as an opportunity for us to get deeper into our communities and understand the unique issues each may face and how we can rally around those to improve overall health. And our results so far give us hope that if we continue this work-and scale things that we are now learning are effective to improving health outcomes-we can have a bigger and bigger impact for our members over time.”

Kayt Sukel is a science and health writer based outside Houston.

How can healthcare organizations better overcome the challenges involved with integrating social determinants of health data into their population health initiatives?

Uniting Determinants and Data for Population Health

Think of a recent consumer experience that you’ve had and odds are it is not related to your use of the healthcare system or related or your health insurance. More often than not, we cite examples from the retail, banking, hospitality or travel industry where elements of transparency, convenience, and reliability combine to generate a memorable and lovable experience. Surrounded by these examples every day, consumers have come to expect the same level of experience in all aspects of their life including healthcare.

Our members also tell us this. Ultimately, they are seeking our help in making their experience simple and affordable. This is no small task. However, we have taken it on with a focus to develop trust, engagement, and activation with those who use our health plan.

An easy-to-navigate web page and mobile experience that provides personalized information (easy access to information about current spend against deductible and OOP limits, finding a high-quality, in-network provider, and more affordable along with access to EOBs) is table stakes these days. Creating relatable, relevant ,and timely communication and tools that demonstrate the value of a health plan to the consumer is where the opportunity lies.

Two key ways to enhance experience are making cost and quality information easily accessible and supporting coordination and navigation of care through consumer personalization and empowerment.

Who enjoys getting a colonoscopy? The idea of prepping for and having the test is a barrier to even going to have a physical at a certain age. In an effort to enhance colorectal cancer screening (CRC) rates, we identified individuals not up to date with screening recommendations who also had no primary care visits in the prior year where a recommendation for screening might occur.

10 Ways to Improve the Patient Experience

Understanding these individuals were not engaging with the care system and knowing a big barrier to CRC screening is fear of colonoscopy, we mailed FIT kits-a home based screening test for CRC-to over 30,000 members along with information on CRC screening and the value of establishing a primary care relationship. The communication was timely and relevant to the audience as just over 24% completed the test and returned the kits. Those with positive findings were all referred for further assessment and screening leading, in some cases, to early cancer diagnoses or identification of polyps requiring more frequent monitoring. Personalizing the campaign increased CRC screening and engaged members with primary care.

Healthcare can be complicated, right? Shopping for prescriptions shouldn’t be. Recently, we launched a pharmacy price transparency tool in our web and mobile experience that provides pricing at any pharmacy. Through a real time benefit check, a consumer can see their OOP cost and plan liability for individual drugs or total cost for all of their prescriptions at a given pharmacy. If a lower cost pharmacy is nearby, they can initiate a transfer of prescriptions with the push of one button.

This has helped save countless dollars for consumers and plan sponsors. This same capability is being piloted in our providers offices to allow the prescriber to see and share with their patient what the real drug costs are based on negotiated rates and current benefit status.

Communications and plan tools must feel relevant and demonstrate value to the consumer if we wish to gain trust and deliver on our members expectations of a simple and affordable experience.

Patient experience should take a front seat at healthcare organizations, but what does that entail?

What Does Simple and Affordable Healthcare Look Like?

President Trump jump-started some proposals for reducing the cost of prescription drugs when he created his American Patients First Blueprint in May 2018.

Unfortunately, drug costs are continuing to affect adults taking prescription medications-especially those who are uninsured. The 

 that 19.5% of uninsured adults in 2017 asked their doctors for a lower-cost medication, 11.4% didn’t take their medications as prescribed, and 5.4% used alternative therapies.

Most people taking drugs say they can afford their treatment, but about 25% have a difficult time paying for their medications, according to 

Here are four areas of reform touted as solutions to the problem:

Lowering OOP payments for Part D beneficiaries

This year saw changes to the Medicare Part D standard benefit in an effort to lower OOP payments paid by Part D beneficiaries.

Under the Bipartisan Budget Act of 2018 (BBA), Part D enrollees’ OOP costs for brand-name drugs in the “donut hole,” declined from 35% of total costs in 2018 to 25% in 2019, while the manufacturer discount increases from 50% to 70%. The Congressional Budget Office (CBO) estimates that these changes will reduce Medicare spending by $11.8 billion over a 10-year period (2018-2027).

Plans’ share of costs for brands decreased to 5% in the donut hole; however, insurers are responsible for 63% of the cost of generics while enrollees pay 37% for them in the gap.

Beneficiary OOP costs before moving into the catastrophic phase jumped from $5,000 in 2018 to $5,100 in 2019 and are expected to rise again in 2020 to $6,350.

The bulk of insurer responsibility is in the initial coverage period-75%-while Medicare is on the hook for 80% of total costs under catastrophic coverage after beneficiaries reach a threshold of $8,140.

Four Ways Hospitals Can Deal with Rising Drug Costs

“While this does create a perverse incentive, payers are still careful about the number and types of drugs they make available on their Part D formularies primarily due to concerns about adverse selection and its impact on overall drug spend,” says Brian Duffant, vice president, BluePath Solutions, a health economics outcomes research consulting firm in Los Angeles.

He acknowledges that insurers have limited ability to move beneficiaries into the donut hole and Medicare to keep them out of the catastrophic phase, based on the standard Part D benefit design (see graphic) that allows a patient to move through the phases of coverage based on total drug and patient OOP costs.  

Legislation has not yet been introduced to modify the BBA coverage gap provisions; however, efforts are underway.

Pharmaceutical manufacturers are pressuring Congress to roll back the manufacturer discount from 70% to 63%, increase Part D plan-sponsor liability, and block an increase in the total amount beneficiaries must spend OOP on their prescription drugs before catastrophic coverage kicks in.

According to the Commonwealth Fund, these proposals would financially benefit drug manufacturers more than Medicare beneficiaries. Beneficiary spending in the coverage gap would be slightly reduced (far more for manufacturers), and Medicare spending under Part D would increase to cover the savings to beneficiaries and manufacturers.

 by the Kaiser Family Foundation states that increasing plans’ shares of costs in the coverage gap, reducing the manufacturer discount to something less than 70% for 2019 and beyond, and modifying the scheduled increase in the OOP spending threshold would result in higher Medicare spending, resulting in a substantial increase in beneficiary OOP cost and fewer Part D enrollees qualifying for catastrophic coverage.

Bipartisan efforts are indicating support for capping OOP spending and shifting more responsibility to insurers by increasing their share of costs in the catastrophic phase, and to manufacturers to lower drug prices.

At the beginning of 2019, CMS green lighted permission for Medicare Advantage plans to use step therapy for Part B drugs covered under Part C to reduce costs and provide more coordinated care.

“The ‘step therapy’ proposal, which was previously not allowed, enables negotiation by manufacturers for discounts related to step therapy for Part B covered under Part C,” says Andy Parece, vice president, life sciences practice, Charles River Associates in Boston. “Approved in 2018 and renewed in 2019, there was limited participation last year, but we expect more in 2019 for 2020 formularies.”

In addition, HHS will test a new payment model to substantially lower the cost of prescription drugs and biologics covered under Medicare Part B. The new model would, for the first time, base Medicare payment for Part B drugs on the typically lower prices paid in 14 other industrialized countries, known at the International Pricing Index.

Medicare’s current payment to physicians for Part B drugs, which is based on the average U.S. sales price for these drugs and biologics, is 47% higher on average than prices paid by these countries for the same products, according to the Administration.

The administration is experimenting with value-based programs for drugs, including indication-based pricing and long-term financing. The Center for Medicare & Medicaid Innovation will test a value-based insurance design model for 2020, including a reduction in cost sharing or additional supplemental benefits for enrollees based on condition, socioeconomic status, or both; awards and incentives; use of telehealth services; and coordinated approaches to wellness and healthcare planning.

Value-Based Model Engages Provider Specialists

Under new guidelines, an indication-based formulary will be available in 2020, allowing Part D plans to choose a different drug for an indication by using step therapy and prior authorization to promote the most cost-effective option. CMS policy currently requires Part D plans to cover a drug for every one of its indications approved by the FDA even if a plan would otherwise have covered a different drug for a particular indication.

Joe Paduda, principal, Health Strategy Associates, a consulting firm in Skaneateles, New York, supports patient-specific formularies as the norm because patients might respond differently to the same therapy. He is concerned, however, that PBMs will use financial measures as a key component of formulary decision making. “Given the need for therapies to reflect each patient’s needs and genetics, patients and prescribers must have access to the right drugs without financial penalty,” he says.

 of employer-sponsored health plans, 60% of employers surveyed believe that permitting importation of less-expensive drugs from abroad is one of the most effective ways to reduce drug prices.

 agrees that importation has the potential to lower healthcare costs for two primary reasons: 1) Patients could access some medicines at lower prices because brand name drugs are generally more expensive in the United States than in other high-income countries; and 2) increased competition from imported drugs could put pressure on drug companies to reduce the price of their products in this country.

The Affordable and Safe Prescription Drug Importation Act, introduced in 2017, would allow pharmacies, wholesalers and patients to purchase drugs and biologics from sellers in Canada who are certified by the HHS secretary.

On a state level, Florida Gov. Ron DeSantis 

 a bill that would allow his state to import drugs. The bill cites a 2003 federal law that allows federal agencies to authorize states to import drugs. DeSantis says that state officials are working with HHS at high levels, and says he has the support of President Trump.

Lower Drug Prices Aren’t Worth Higher Health Risks

Ed Schoonveld, managing principal, ZS Associates, a Chicago-based biosciences consulting firm, supports differential pricing (up to the level that variable cost allows), but notes it has some hurdles. “The critical factor in enabling differential pricing is the willingness of high income countries to accept it. Recent initiatives in the United States and Canadian pricing reform (the Canadian government is changing its basket of reference countries by removing the United States and Switzerland and adding lower priced countries such as Australia and those in Eastern Europe) are part of the challenge,” he says.

While some worry about the loss of R&D funds for pharmaceutical manufacturers, Schoonveld sees new opportunities to recoup potential losses. “There is a lot of pressure to make drugs available at affordability levels in low- and middle-income countries. In most cases, it would likely be in the interest of all patients worldwide (and the industry) if prices could be adjusted to affordability levels as higher volumes of patients, now enabled to use the drug, would add at least some marginal contributions to the global cost of R&D,” he says.

Two more Trump administration proposals to decrease drug costs-mandating that drug manufacturers disclose list drug prices in TV ads and an overhaul of the drug rebate program-are off the table as of July 2019.

Opportunities to lower drug prices, as promised by President Trump’s American Patients First Blueprint, are picking up steam, some progressing more quickly than others.

Drug Price Reform Takes Off in 2019

Multiple sclerosis (MS) is a chronic inflammatory condition that affects the central nervous system (CNS), and it can result in significant disability and death. According to the 

, more than 2.3 million people are living with MS worldwide, and disease-modifying therapies (DMTs) are considered the mainstay of therapy to help to reduce the frequency and severity of relapses. However, these medications are also associated with adverse effects ranging from mild to life-threatening. Current phase 3 studies are investigating new ways and novel approaches to prevent MS relapses.

Healthcare executives are concerned about the cost, quality, and outcomes of MS drugs, making it a top priority for patient care and expenditures. According to a study published in 

 out-of-pocket monthly costs for MS medications increased from approximately $15 to about $309 over 12 years. According to the 

, the average median price of MS DMTs in 2013 was less than $60,000 while the price in 2018 was $80,000. Patients with MS also face co-insurance that could be as high as 40%, which translates into a monthly cost of over $2,500 for their DMTs.

Legislation that makes MS medications more affordable is needed to alleviate patient costs. Healthcare professionals can play an important role through an interdisciplinary approach to managing patients with MS and identifying financial options such as patient assistance programs to alleviate costs.

Erin Lopata PharmD, MPH, Senior Director, 

Access Experience Team at Precision for Value

 points out that Tecfidera (dimethyl fumarate) is approaching the end of its patent exclusivity, and there are several similar medications that are anticipated for FDA drug approval. Lopata adds that Vumerity (diroximel fumarate) is a prodrug for monomethyl fumarate, which is the active metabolite of Tecfidera and may cause less gastrointestinal adverse events.

Interim efficacy and safety results from the 

 study were recently presented at the AAN Annual meeting, and showed that after 48 weeks, relapse rates decreased by about 79% relative to baseline. Biogen has submitted the new drug application (NDA) and approval of Vumerity is expected sometime in 2019.

 for Bafiertam (monomethyl fumarate) for relapsing forms of MS. Lopata discussed that Bafiertam is the active metabolite of both Tecfidera and Vumerity, and its launch is anticipated for June 2020. 

 has submitted its NDA for ozanimod for the treatment of adults with relapsing forms of MS. The FDA previously rejected the NDA based on insufficient data, but it is expected to receive approval based on the new submission on March 25, 2020. Data is based on the 

 trials, which demonstrated that ozanimod was effective at preventing MS relapses.

The Latest Autoimmune Disease Treatment Advances

Ozanimod is an oral sphingosine 1-phosphate (S1P) receptor modulator. “With a mechanism of action similar to the recently approved Mayzent (siponimod) and an optimal pharmacokinetic profile, ozanimod hopes to demonstrate an improved safety profile to Gilenya (fingolimod),” says Lopata. Ozanimod has only been studied in relapsing forms of MS; however, Mayzent is FDA approved for both relapsing and secondary progressive populations.

“With the success of Ocrevus (ocrelizumab) for MS, additional CD20-directed monoclonal antibodies are likely to follow,” says Lopata.

Another candidate on the horizon is ublituximab (TG-1101), which is being studied by the biopharmaceutical company 

. Ublituximab is a monoclonal antibody that targets the CD20 antigen, and anti-CD20 antibodies have been shown effective in treating various conditions including MS. The company recently announced 

 at the AAN annual meeting showing that the drug is well tolerated. Phase 3 trials known as 

 (NCT03277248) are currently being conducted to assess the safety and efficacy in patients with relapsing MS.

Jennifer Gershman, PharmD, CPh is a pharmacist and medical writer residing in South Florida.

MS is in need of new medications-these could be the future.

What’s New in the MS Drug Pipeline

As cardiac disease, diabetes, and other chronic illnesses rise worldwide, and as the population ages and the U.S. faces a predicted physician shortage, many health systems and health plans have embraced 

 as an option to grow their markets and continue care to patients remotely.

 on health insurance claims from across the country found that between 2016 and 2017 telehealth claims increased by 53%-more than both urgent care centers (14%) and retails clinics (7%) combined.

“From a business perspective, if I can keep you healthier and more compliant with your physician recommendations, hopefully your health outcomes are going to be more positive. That means where we can potentially reduce readmission disease exacerbations and emergency room visits,” says Marya Vande-Doyle, director of workplace wellness and telemedicine for 

 (BCBS). The health plan recently reported that nearly 15,000 telemedicine claims were filed in 2018. “We see telemedicine as a way to ensure that members feel like they have access to care wherever they go.”

Combined with market factors, CMS also accepted 

 in 2019 allowing for providers to be paid for remote patient monitoring, e-visits, and e-consults.

But even with a ripe market and more CMS support, experts believe that healthcare organizations still have a long way to go before telemedicine and e-visits are commonplace. Zynn says state regulations can still be a hurdle to telehealth adoption.

“If you asked anybody in the industry, they would say licensing and changes in the regulations at the state level are probably the biggest hurdle or hindrance to faster growth,” says David Zynn, president of Infectious Disease (ID) Connect, a telemedicine company recently spun off from the University of Pittsburgh Medical Center (UPMC).

, which provides streamlined licensure for physicians who offer telemedicine services through multiple states.

“In the next five years, we'll lose the term ‘tele’ because it will just be healthcare,” says Zynn. You will make an appointment to see your doctor and either go to the hospital or get that service via telemedicine. You will also get follow ups via telemedicine. So, it’s more efficient, more effective, and better for the patient.”

Using telehealth to expand specialists’ reach

UPMC saw telehealth as an opportunity to offer its expertise in infectious disease to communities across the country. The hospital launched a telemedicine company, ID Connect, to help other hospitals improve outcomes and reduce transfers for patients who need infectious disease treatment.

Currently, the program is being used by several other hospitals and outpatient clinics, with plans to expand in the upcoming months. A shortage of physicians who specialize in infectious disease, coupled with the constantly-evolving nature of the field were other catalysts to UPMC’s decision to create a technology company focused on providing services more broadly.

ID Connect incubated at UPMC for the past five years, and Zynn says that through that trial they were able to prove that telemedicine could contribute to a decrease in 

, patient hospital stays, and mortality. Currently, 12 doctors are providing services on the platform to other doctors who need assistance or second opinions, and to patients who are recommended to a specialist.

“Our doctors schedule tele-physical exams and we train our customers to use a tele-presenter. It is still is a very comprehensive exam, with questions, history, and a physical exam. The tele-presenter also has a video, so that our doctors can see and hear everything as if they were physically present,” Zynn says. “Our doctors can diagnose, treat, order labs and prescriptions, all documented in the EHR. They will follow up with that patient to make sure everything is working out as planned. They can make any changes to the diagnosis or treatment plan if necessary. And upon discharge, a telehealth appointment would be part of the discharge order and follow up.”

Zynn says that because there are more than 4,000 hospitals with 300 beds or less, it is increasingly important for smaller providers to have easy and affordable access to specialists. The U.S. could be short up to 122,000 physicians by 2032, with possibly half of them projected to be specialty care providers, according to 

 from the Association of American Medical Colleges.

“I’ve talked to our customers and the number one thing that we bring to them is, without our service, they would have to transfer a lot of patients out to a larger tertiary. That’s not good patient service,” Zynn says. “It's not good for the local hospitals because they lose that patient. You don't want to take someone who is very sick with an infection and transport them from one facility into another. That alone is a tremendous opportunity to improve care.”

Health plans increasing telehealth outreach

Health plans are also seeing positive impacts to increased telehealth adoption. A recent claims review from Excellus BCBS in New York found that telehealth services have tripled in the past two years. The health plan’s review found that nearly 15,000 telemedicine claims were filed in 2018, up from 5,100 in 2016.

A survey of more than 2,000 Excellus BCBS members conducted in 2019 found that more than half of members knew about telemedicine and 43% said they would consider using it in the future. Though only 5% reported using telemedicine services, 93% who used it rated their experiences favorably.

An increase in community outreach and provider education are factors that led to the increase in telemedicine claims, Vande-Doyle says.

“We provided a public service campaign to help spread awareness using local media and partnering with community events, to help the community understand what a telemedicine visit is,” Vande-Doyle says.

New Payer-Technology Partnerships Could Be Telehealth’s Future

The second approach Excellus BCBS took was to work with network partners, health systems, and primary care providers based in the community and the local and state medical society to share why telemedicine is important. Excellus BCBS services Medicare, Medicaid managed care, commercial, and employer-based health plans.

“A vast majority of our population is located in either health professional shortage or metropolitan shortage areas as designated by HHS. We recognize that for those members it's very difficult for them to travel during a snow storm or find a caregiver to drive them to a doctor's appointment. We reached out to the medical community understanding these common challenges and how can we increase awareness of telemedicine,” Vande-Doyle says.

The Excellus BCBS survey results found that 78% of telehealth services were related to heart disease, hypertension, skin disorders, diabetes, and pneumonia. Another 22% of services were related to behavioral health, including anxiety, depression, attention and bipolar disorders. Behavioral health visits via telehealth were the fastest growing areas of treatment, according to the claims review.

“In order to be successful, we have to ensure that our providers feel comfortable in offering telemedicine. We have to encourage our providers to innovate. And at the same time, we have to share what we're learning,” Vande-Doyle says. “It's not focused on one specialty, healthcare provider, or one visit type. Telemedicine is for all types of applications. It's part of a solution of increasing access to care and using our healthcare services.”

In the last decade, PipelineRx has grown its telepharmacy business to serve more than 600 hospitals and provider organizations, with 150 telepharmacists working from a call center or remotely. Brian Roberts, CEO of 

, says that remote dispensing and medication management, along with counseling patients and providers delivers education and efficiency that is lacking in the healthcare system.

“Telepharmacy increases access to facilities or organizations that either can't afford or can’t find the right pharmacy personnel. We can provide that remotely so that everybody has 24/7 care,” Roberts says. “I can take one telephone pharmacist working from home or from our call center, and they can cover between four and seven facilities at the same time. You can bring the overall cost of managing those facilities down by using telepharmacy.”

Roberts says that telepharmacy can allow on-staff pharmacists the ability to focus less on administrative tasks and work more closely with patients.

The state of telemedicine and remote patient monitoring.

Managed Healthcare Executive August 2019 Issue

Top Payer Growth Strategies

New Report is Tackling Workplace Opioid Abuse

Top 3 Issues for Hospital Executives

Uniting Determinants and Data for Population Health

What Does Simple and Affordable Healthcare Look Like?

Drug Price Reform Takes Off in 2019

What’s New in the MS Drug Pipeline

Telemedicine and E-Visits: An Update

The Future of Healthcare Wearables

Top 7 Qualities of the Ideal Executive Assistant

14 Ways Insurers Can Improve Patient Experiences

How Mentors Inspire Health Execs