DBN: 2011 Pharmacy Predictions

Drug Benefit News (which is a must read publication) just came out with a summary of opinions from people about the new year (DBN, 1/7/11).  Here are a few highlights:

  • Focus on clinical programs to help MCOs hit their MLR targets
  • PBM consolidation and need for smaller PBMs to innovate (as my whitepaper discusses)
  • Potential for generic only formularies as generic fill rate is in the 70-80% range
  • Focus on specialty drug costs including the claims processed under the medical benefit (Express Scripts big push right now)
  • Outcomes based contracting (i.e., Merck and Cigna)
  • Direct contracting (i.e., Caterpillar, Delta)
  • Continued pharma shift to niche markets as brand oral solids make up <20% of claims
  • Health reform fallout
  • Continued streamlining and focus on MA and PDP
  • Continued innovation (i.e., Wal-Mart and Humana model)
  • Limited or restricted networks take off (finally)
  • Cost plus pricing
  • Modernizing Medicaid management and controlling costs

I was one of the people interviewed for the article.  My comments from the article are:

The things that I’m monitoring and think will affect the industry include mobile health, behavioral science application, preference-based marketing, risk based contracting, and integration with home monitoring devices. Rising costs will push several things such as increased management of the specialty benefit, more focus on adherence, and an increased understanding of how consumers impact health outcomes and how to best engage them. In 2011, innovations and changes in benefit design could include limited networks, more and more utilization management especially step therapy and 90-day retail or mail.

The biggest area of discussion in Medicare Part D right now is the Star Ratings. There are questions for PBMs about how they support the MA metrics and there are now specific PDP metrics. Understanding what those are, how to track them, how to influence them, and how to improve them will be a major focus in 2011.

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