The Third National Medicare Congress Marketplace Assessment of Drug Plan Options: MA-PDs and PDPs Scott G. Hughes R.Ph. October 17, 2006.

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Presentation transcript:

The Third National Medicare Congress Marketplace Assessment of Drug Plan Options: MA-PDs and PDPs Scott G. Hughes R.Ph. October 17, 2006

MemberHealth, Inc. 2 Agenda Introduction – the MemberHealth CCRx Team Part D to date – Beneficiaries and Enrollment Part D – By the Numbers 2006 and 2007 Prospects for enrollment 2006 and beyond CMS Data and Initiatives Pharmacy’s role in Part D Administration MemberHealth Initiatives Strategic Initiatives – PDPs and MA-PDs

MemberHealth, Inc. 3 The MemberHealth, Inc. Community Care Rx Part D Team MemberHealth, Inc. - one of the nation’s most innovative pharmacy benefit administrators with over 61,000 pharmacies in its nationwide network. MemberHealth is the 4 th largest Part D PDP and one of only 10 national Part D PDPs in (one of 17 in 2007) National Community Pharmacists Association - represents the pharmacist owners, managers, and employees of nearly 25,000 independent community pharmacies across the United States. Independent pharmacists - more than 60,000 nationwide - dispense the majority of the nation's retail prescription drugs NACDS Chain Members

MemberHealth, Inc. 4 Community Care Rx Strong relationship with NCPA and NACDS members Auto enrollment in 23 regions in 2006; will retain/qualify for duals in 27 regions in 2007 Broad network (61,000+ pharmacies) Broad formulary Aligned incentives Leveraging and strengthening the relationship between pharmacist and beneficiary

MemberHealth, Inc. 5 Where are the Medicare Beneficiaries? 43,404,884 TOTAL Medicare Beneficiaries 10.1 signed up with PDPs (Rx only) 6.3 in MA-PD (Medicare Advantage) 6.1Dual Eligibles (auto enrolled in PDPs) 22.5 Total enrolled in Part D 6.9in Employer Plans (creditable coverage) 3.5Federal Retirees (Tricare,VA etc.) 5.4additional sources of creditable coverage 15.8 Total other coverage 38.2TOTAL with Drug Coverage 4.4 Est # of beneficiaries with no creditable drug coverage. 3.25M may be LIS elig.

MemberHealth, Inc. 6 Where’s the Enrollment? Organization# of Enrollees% of Total Enrollment United/Pacificare4,458, % Humana3,421, % Wellpoint1,105,3116.8% MemberHealth964,3125.9% Wellcare872,3625.4% Source: CMS as of 7/1/06

MemberHealth, Inc. 7 Where’s the Enrollment? Organization# of Enrollees% of Total Enrollment “Top 11” PDPs13,242, % All PDPs16,213, % MA-PDs6,278, % TOTAL Part D22,491,177 Source: CMS as of 7/1/06

MemberHealth, Inc. 8 Part D Plans – 2006 By The Numbers PDP –1429 total plans –28.2% with a premium below $30 –58.4% with zero deductible MA-PD –314 HMO and Local PPO plans –96.2% beneficiaries with access to an MA-PD Source: Kaiser Drug Plan Tracker

MemberHealth, Inc. 9 Part D Plans – 2007 By The Numbers PDP –2,844 total plans (nearly double 2006) –All states except AK and HI have > 50 plans –17 National Plans (up from 11) –83% of beneficiaries will have access to a lower premium –Avg premium $24 (same as 2006 and 40% less than est.) –Median premium $33.40 in 2007 vs $36.01 in 2006 –4,390 meds in average formulary; up 13% –Fewer prior authorization and other formulary management tools –More gap coverage (generics in every state)

MemberHealth, Inc. 10 Part D Plans – 2007 By The Numbers MA-PD –(# to be announced) –Expect dramatic increase in SNP options –Expect nearly 100% of beneficiaries will have access to an MA-PD –MA-PDs offer competitive premium against PDPs –MA-PD enrollment expected to triple to 15.3 million by 2013

MemberHealth, Inc. 11 PDP vs MA-PD Avg. Premiums PDP$37 Regional PPO$21 Local PPO$27 Local HMO$16 Local fee-for-service $17

MemberHealth, Inc. 12 Prospects for Enrollment – 2006 and Beyond - Target Markets Coverage Gap Beneficiaries Low Income Subsidy Employers MA-PDs SNPs Dual Eligibles (new) SPAP's New Beneficiaries

MemberHealth, Inc. 13 The Coverage Gap Beneficiary Generally favorable impression of Part D among enrollees – will they still be happy in the gap? 8% or 3.4 million beneficiaries will be fully responsible for payment in the gap 38% have coverage from outside Part D (employer, etc.) 23% are LIS and have no $$ outlay in the gap 6% chose enhanced plans with some gap coverage 16% will never reach the gap (spending below $2250) Source: PricewaterhouseCoopers

MemberHealth, Inc. 14 Importance of Duals/LIS to Plans 14 million duals and LIS eligibles – one third of all Medicare beneficiaries LIS enrollment key CMS focus Low application rate; ineligible because of asset test 3.25 million yet to enroll Risk adjustment should limit risk associated with higher costs for duals Retention - need to provide good service to keep dual/LIS enrollees

MemberHealth, Inc. 15 Employers and Coalitions 11 million covered under Employer/Union plans 77% took the federal subsidy in % were in other plans, including wraparounds 17% were in Employer/Union programs –9.3% MA-PDs –4.6% PDO –1.2% direct % somewhat or very likely to take subsidy % or less projected likely to take subsidy

MemberHealth, Inc. 16 MA-PD Market – What will they choose? Largely income and illness driven –Medicare Advantage MSAs (high income) –Medicare Advantage PPOs –Medicare Private fee-for-service plans –Medicare Advantage HMOs –Medicare Advantage Specials Needs Plans (the low income high illness patient)

MemberHealth, Inc. 17 New Part D Data Released - 7/28/06 CMS posted plan-level Medicare Advantage (MA), Cost, PACE, Demo, and Prescription Drug Plan (PDP) enrollment data. Data reflects enrollment counts paid for the month of July Plan-level data will be posted once a year during the month following the conclusion of the MA open enrollment season. All other months of the year, CMS will post MA and Part D enrollment data at the contract level. Additionally, CMS will post a summary of enrollment by organization type. Annual Report by Plan available in the "downloads" section at: entData.asp

MemberHealth, Inc. 18 CMS Publishes Complaint Data Overall Complaints ( June ‘06) 2.3/1000 –PDPs 2.6/1000 –MA-PDs 1.4/1000 Complaint Type PDP MA-PD Benefits/Access Enrollment/Disenrollment Pricing/Coinsurance Other

MemberHealth, Inc. 19 Estimated Part D Prescriptions Filled Jan thru May Est. Rxs # % –PDP –MA-PD –Duals –Retiree subsidy –Fed retirees –Alt. creditable cvrg TOTAL 533.9

MemberHealth, Inc. 20 Pharmacies Role in Part D Administration Under Part D Pharmacists can Educate and Inform – cannot steer; cannot enroll patients –Compliance will be strictly enforced by CMS and Plans Pharmacists have a key educational role as the most frequently visited and most trusted healthcare professional Assisting patients in understanding Part D and educating them on choices and how to enroll Transition Period Management, Formulary Management

MemberHealth, Inc. 21 MemberHealth Initiatives Medication Review as part of transition Medication Therapy Management Formulary Management Tools Outreach to States (SPAPs, AAAs, etc.) Exploring ways to assist with LIS applications MA – PD Employer Groups e-Prescribing

MemberHealth, Inc. 22 Welcome to CCRx Medication Review Part of transition plan Face-to-face review of new enrollees’ medications with community pharmacist Address both clinical and cost issues Initiate exceptions processes if needed No cost to enrollee For any new enrollee after June 1

MemberHealth, Inc. 23 CCRx Medication Therapy Management (MTM) Focused on Pharmacist-Patient Relationship Delivered through new industry communications system – Community MTM Services, Inc. –Larger opportunity for Medicaid programs to connect with pharmacists to improve patient care management

MemberHealth, Inc. 24 Formulary Management Tools Fears of formulary instability unfounded 2007 Formularies had to be submitted before much data gathered New generic availability the largest factor Changes will focus on tiering strategy related to 2007 bid strategy

MemberHealth, Inc. 25 Strategic Initiatives – PDPs and MA-PDs Market Consolidation – 2007 and on Driven by: –Enrollment –Marketshare –Revenue Management MA-PDs left a lot on the table; PDPs could not Risk Corridors Risk Adjusters –Cost Management –Member Service and Retention –Who can Prove Value and Cost Management?

MemberHealth, Inc. 26 QUESTIONS MemberHealth Contact Information –Scott G. Hughes R.Ph. –