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Louisiana’s Medicaid Pharmacy Benefits Management (PBM) System

Department of Health and Hospitals. Louisiana’s Medicaid Pharmacy Benefits Management (PBM) System. Louisiana’s Medicaid PBM. Rx benefits for Medicaid Recipients (Began 1966 with implementation of Medicaid Program) State owned and operated PBM Not for Profit

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Louisiana’s Medicaid Pharmacy Benefits Management (PBM) System

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  1. Department of Health and Hospitals Louisiana’s Medicaid Pharmacy Benefits Management (PBM) System

  2. Louisiana’s Medicaid PBM • Rx benefits for Medicaid Recipients (Began 1966 with implementation of Medicaid Program) • State owned and operated PBM • Not for Profit • All savings derived from PBM Accrue to Benefit of State

  3. Louisiana’s PBM Components • Manufacturer Rebate Maximization – Federal & State • Provider Audits • Patient Profiling • On-Line Prescription Reporting • Provider & Patient Reporting • Lock-In for Misutilizers • Coordination of Benefits (Third Party Liability) • Program Oversight – CMS, AG, OIG & DHH • Provider Network Development • State Maximum Allowable Costs (MACS) • Provider Fees • Co-payments • Preferred Drug List • Prior Authorization • Monthly Prescription Limits • Provider Help Desk • Claims Management

  4. Additionally, Louisiana’s PBM Offers: • Cognitive Services – Pharmaceutical Care Intervention/POS System Captured • Electronic Clinical Data Inquiry Application (e-CDI) • Outcomes Management • E-Prescribing Program • Clinical/Intervention Desk • Physician /Pharmacy Education Programs • Disease Management – Patient and Provider Educational Programs • DUR – Prospective, Education & Retrospective

  5. Louisiana’s Medicaid PBM Controls 1990’s 1960’s PBM Cost Containment • Omnibus Budget Reconciliation Act OBRA 90 (1990) • Required Sate Level DUR • Required Patient Profiles • Required Patient Counseling • Implemented Manufacturers Drug Rebates and DUR (1991) • $0.10 Provider Fees (1992) • Office of Mental Health Discontinues Drugs for Patients; Drug Cost • Assumed by Pharmacy Program • Expanded Lock-In Program • Implemented Co-pay Controls • Pharmacy Benefits Management System • Medicaid Pharmacy Benefits Management Advisory Work Group Created to Maximize Program Efficiency and Effectiveness • Interdisciplinary Counsel Comprised of Health Care Executives Formed (1995) • Billings System Implemented Requiring Provider to Bill Medicare first • for Dual Eligibles (1996) • Rx benefits for Medicaid • Recipients (1966) • Comprehensive Audit Program • (1966) • Prior Authorization Cost Containment • Program (1966-1974) 1970’s • Peer and Utilization Review Committee (1976) • First MMIS (1977) 1980’s • Recipient Lock-In (1980) • State Maximum Allowable Cost (MAC) (1984) • Restricted Formulary Instituted (1988) • Restricted Formulary Repealed by Act 403 (1989) 2000’s • Provider Peer Based Profiling (2002) Preferred Drug List & Prior Authorization (2002) • Supplemental Rebates (2002) Prescription Limit (8/month) (2003) • Clinical Drug Inquiry Applications (2003) HIPAA Compliant (2003) • Coordination of Benefits 2003 Provider Audits (2004) • Disease Focus DUR-2004 Antipsychotic DUR Initiative -2005 • Part D Implementation (2006) Asthma HELP (2006) • E-Prescribing (2008) Medicaid Rx Cost

  6. Pharmaceutical and Therapeutics Committee Overview • ACT 395 of the 2001 Regular Legislative Session– • Authorizes the Department of Health and Hospitals (DHH) to establish a drug list utilizing a prior approval process or any other process or combination of processes that prove to be cost effective in the Medical Assistance Program • Allows DHH to enter into contractual arrangements to perform the prior approval (PA) function

  7. Pharmaceutical and Therapeutics Committee Overview • The Louisiana Medicaid Pharmaceutical and Therapeutics Committee (P & T): • Established in August 2001; • Consists of twenty-one (21) members, appointed by the Governor; • Reviews clinical and cost data on various Therapeutic Classes of drugs; and • meets Bi-Annually.

  8. Pharmaceutical and Therapeutics Committee Overview • On June 10, 2002, the Department implemented a Preferred Drug List (PDL) with a Prior Authorization (PA) process and a Supplemental Drug Rebate Program through a phased-in approach • The University of Louisiana at Monroe (ULM) School of Pharmacy administers the PA function; • DHH contracts with Provider Synergies to negotiate State Supplemental Rebates; • Beginning Calendar Year 2011, the committee will meet in May and November • The Preferred Drug List is updated bi-annually (July & January) based on committee’s recommendations

  9. Pharmaceutical and Therapeutics Committee Overview • Provider Synergies, LLC • Negotiate State Supplemental Rebates with Drug Manufacturers • Prepare therapeutic class reviews • Provide cost analysis information for the therapeutic classes • Develop clinically sound and cost-effective recommendations to develop and manage the PDL

  10. Therapeutic Classes Reviewed 75 68 57

  11. Preferred Drug List and Supplemental Rebates • Seventy – five (75) therapeutic classes are included in the PDL review process • Provider Synergies has projected $38,625,704 in program savings for SFY 2010 resulting from market shift and supplemental rebates. • The PDL compliance rate for SFY 2010 was approximately 91%. • The Pharmacy program contracts with Provider Synergies to negotiate state supplemental rebates with drug manufacturers and assist with maintenance of the PDL. 

  12. Pharmacy Program ExpendituresSFY 2008 - 2010 Source: Medical Vendor Report, Data Warehouse, LAPRIMS & MW-M-01 Rebate Total computations do not include interest and all figures were derived from State Fiscal Year parameters

  13. Louisiana Medicaid Pharmacy BenefitsManagement Program SavingsState Fiscal Year 2010 Program M $283,640,228 Program J $ 6,422,925 Federal Rebates $290,063,153 Supplemental Rebates 42,740,235 Refund checks (37,154) Prospective DUR 50,197,386 Dispensing Fee ($5.77 (MAX) $4.39 (AVG) (10,879,384) 15,013,550 Co-payments 7,816,502 Pharmacy Provider Fees 8,042,084 Medicare Crossovers 11,979,819 Recoupment Audit 327,721 Rebate 1,218,451 TPL Savings 25,872,125 TOTAL $453,233,873

  14. Medical Assistance Program & Pharmacy Statistics • Total Medical Assistance Program expenditures for FY 2009: $6,741,437,953 expenditures for FY 2010: $6,638,648,061 • Total Medical Assistance Program drug expenditures for FY 2009: $828,021,081 expenditures for FY 2010: $854,671,680 • Total number of prescription claims reimbursed through Medicaid in FY 2009: 10,180,045 Medicaid in FY 2010: 10,879,384 • Total dollars spent on prescription drugs Prescription Drugs in FY 2009 (net of rebate): $526,575,313 Prescription Drugs in FY 2010 (net of rebate): $521,905,446 Average prescription payment for FY 2009: $81.34 Average prescription payment for FY 2010: $78.56

  15. Historical View SFY (2000 – Present) State Fiscal Year Unduplicated Unduplicated Rx (SFY) EligibleRecipientsRecipients 2000/01 825,678 781,073 646,694 2001/02 909,912 853,672 693,743 2002/03 952,453 894,129 729,057 2003/04 1,061,487 1,048,021 770,350 2004/05 964,106 914,587 790,168 2005/06 980,697 870,640 791,967 2006/07 1,153,903 1,121,205 737,380 2007/08 1,131,357 1,119,484 772,696 2008/09 1,075,596 889,549 800,831 2009/10 1,293,458 1,231,803 861,179 Source: Medicaid Annual Reports, Data Warehouse & MW-M-01, SFY 1995/96 through 2009/10

  16. Average Cost Per Claim SFY 2008 - 2010

  17. Generic Utilization Percentage SFY 2008 - 2010

  18. Average Rx/Recipient SFY 2008 - 2010

  19. Average Rx Paid/Recipient SFY 2008 - 2010

  20. Select Chain Provider Claim Counts Paid Amount < $12 SFY 2008 - 2010

  21. Total Prescription Costs: Pre- and Post-Lock-in

  22. Retrospective DUR (LADUR) HYPERTENSION (HTN) MANAGEMENT • RECOMMENDED JNC 7 GUIDELINES • RECOMMENDED INITIATION OF HTN TREATMENT FOR STAGE 1 AND STAGE 2 HTN WHEN NO TRTMT NOTED • FOLLOWED UP WITH PHONE CALLS TO NON-RESPONDERS 34% STARTED AN ANTI-HYPERTENSIVE AGENT

  23. Retrospective DUR (LADUR) DIABETES MANAGEMENT • RECOMMENDED A1C TESTING BE PERFORMED • 41% HAD LAB TEST PERFORMED • RECOMMENDED ACE INHIBITOR OR ARB TO DIABETICS WITH HYPERTENSION • FOLLOWED UP WITH PHONE CALLS TO NON-RESPONDERS (ULM) • 26% ADDED ACE INHIBITOR OR ARB • RECOMMENDED DISCONTINUING THIAZOLIDINEDIONE or METFORMIN to diabetics with HEART FAILURE • 31% DISCONTINUED DRUG

  24. Retrospective DUR (LADUR) HEART FAILURE • RECOMMENDED ADDING BETA BLOCKER • 21% ADDED BETA BLOCKER • RECOMMENDED ADDING ACE INHIBITOR • 29% ADDED ACE INHIBITOR • RECOMMENDED DISCONTINUING NSAID in heart failure patients • 63% DISCONTINUED NSAID

  25. LA Medicaid PBM Electronic Clinical Data Inquiry Application (e-CDI)

  26. Electronic Clinical Data Inquiry Application (e-CDI) • Internet Web-Based • Available 24 hours/day • Updated on a daily basis • Print friendly version

  27. Electronic Clinical Data Inquiry Application (e-CDI) • Each Medicaid recipient • All drugs dispensed • This month • Last month • Last four months • By all prescribers

  28. Electronic Clinical Data Inquiry Application (e-CDI) • Availability of data • Any practice location • Office or Pharmacy • Emergency Room • Hospital or Clinic

  29. Electronic Clinical Data Inquiry Application (e-CDI) • Benefits: • Evaluate drug usage • Similarly clinically effective drugs • MD/Recipient • Unsure of drugs

  30. Electronic Clinical Data Inquiry Application (e-CDI) • Benefits: • Assist with: • Monthly prescription limit • D/C drugs • Less costly drugs • More clinically

  31. Electronic Clinical Data Inquiry Application (e-CDI) • Benefits: • Better drug outcomes due to: • Drug mishaps • Duplication • Side effects • Overmedication

  32. Electronic Clinical Data Inquiry Application (e-CDI) INFORMATION COMPONENTS: • SERVICES (Paid Claims) • CLINICAL DRUG INQUIRY • MD/EPSDT • PROCEDURES (OP) • SPECIALISTS • LAB & X-RAY • EMERG. RM. • INPATIENT • ANCILLARY

  33. CLINICAL DATA INQUIRY APPLICATION

  34. LA MEDICAID PBM CDI • How to Access CDI: • www.lamedicaid.com • Provider log-in • 7-digit Medicaid Number • Your online account • Activation of account • CDI link to view recipient information

  35. THANK YOU! Your Logo

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