CAA Plan Sponsor Obligations for PBMs
At MBGH's 2022 Employer Forum on Pharmacy Benefits & Specialty Drugs our keynote speaker, Jonathan E. Levitt, Esq from Frier Leavitt, discussed Plan Sponsors’ fiduciary obligations under the Consolidated Appropriations Act (CAA). He graciously agreed to provide a draft communication for employers to send to their contracted PBM to request the data elements required under the CAA. The deadline for employers to submit this data to the federal government is December 27, 2022.
*Please note that grandfathered Plans are not subject to the CAA requirements*
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Are Payment Practices Leading to Unintentional
Opioid Use?
The surgical setting introduces many patients to opioids. While opioids are inexpensive, they come at a cost. Estimates suggest that greater than 2 million surgical patients become persistent opioid users each year, costing society more than $13 billion annually. Despite their widespread use, 72% to 88% of patients still report moderate-to-severe pain in the first 72 hours after surgery. Non-opioid post-operative pain medications, administered directly into the surgical site, have proven highly effective in managing post-surgical pain and greatly reduce the need for opioids. Employers play a pivotal role in making these new alternatives available to their members.
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Prescription Digital
Therapeutics (PDTs)
As part of today’s new frontiers in digital health, PDTs are a new therapeutic class that uses software as medicine. PDTs offer patients additional avenues to overcome treatment access barriers that are often associated with medications or in-person therapy. They are defined by their clinical efficacy and FDA market authorization and have the ability to diagnose, prevent, manage or treat a medical condition on its own (or in combination with medications, devices or other treatments to optimize patient care). Employer benefits include the opportunity to deliver safe, noninvasive, non-drug and cost-effective solutions to support employees and members.
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Obesity Management
Obesity is recognized by the CDC, AMA and the FDA as a multi-faceted chronic disease requiring long-term management. It is a complex condition affecting more than 31% of full-time employees - another 37% in the workforce are overweight. The good news is that even a small amount of weight loss (5% of a person’s total body weight) can have a clinically meaningful impact on many obesity-related comorbidities and complications, leading to health care cost savings and improved health. Use these briefs to help tackle the obesity epidemic at your organization and support your members in their weight loss journey.
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Non-Alcoholic Fatty Liver Disease
(NAFLD)
Liver disease is a silent epidemic that affects millions of Americans and imposes a significant financial burden on employers. As a matter of fact, 22% of Americans have non-alcoholic fatty liver disease (NAFLD) and for those with obesity, 80-90% are affected. Because there often are no symptoms, NAFLD can progress to cirrhosis and liver failure with few warning signs. The good news is that early detection and lifestyle modification can reduce the progression of this disease. Employers should be aware of new testing options and treatments to mitigate the high cost of treating advanced liver disease.
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Chronic Low Back Pain
(CLBP)
As one of the top three most costly conditions in the U.S., chronic low back pain (CLBP) is a significant burden to employers not only due to health care costs but disability and productivity impacts. Did you know that fewer than half of those disabled due to CLBP for longer than six months return to work and after two years, the return-to-work rate is close to zero? This action brief outlines the pros and cons of the many different CLBP treatment options available and provides detailed action steps employers can take to proactively manage this condition, improve outcomes and impact the total cost of care.
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State Legislative Impact
on the Cost of Insulin
Affordability of insulin directly impacts the adherence and health status of those living with diabetes that require insulin. Many states have implemented legislation for maximum copays on the cost of insulin to address this issue. State legislation only impacts state-regulated health plans. Self-insured employers can set their own coverage limits to make this life-saving medicine affordable. This action brief offers best practices for High Deductible Health Plans (HDHP), brings insight into what MBGH employers are saying and provides employer action steps.
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Hemophilia
& Bleeding Disorders
This brief provides resources to more effectively manage the high cost of hemophilia and improve the lives of those impacted by this rare but serious disease. Vetted by health benefit professionals from employer member companies, this resource is available to employers across the country to help them: Better understand hemophilia prevalence and related cost; Identify how benefit plan design can support (or hinder) best in class treatments; and Understand the steps to take with vendors to improve overall quality of care and reduce waste.
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Jointly Addressing
Mental Health
The Mental Health Collaborative – a group of nine organizations that are members of the non-profit Midwest Business Group on Health – identified access to mental health services as the primary concern in the assessment and treatment of the disease. The group seeks to work across all stakeholders to identify and implement solutions. This brief defines the need for improved mental health services specifically addressing the problem of access to care and offers solutions and action steps for stakeholders.
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Precision Medicine in
Pharmacy Design
Pharmacogenomics, Precision Medicine, Pharmacogenetics, human genome and genetic testing have become frequent terms that benefit leaders and consultants use as they design their benefit offerings, particularly with pharmacy benefits. Given that cost and quality care are top of mind for employers today, it is essential that adequate access and plan design features are in place to both ensure members have access and to control costs. This brief explores how these terms characterize ways an individual's genes affect their response to medications and how they are being used specifically within the pharmacy benefit for self-insured employers.
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Transforming Pharmacy Benefits:
Role of Biosimilars
Costs continue to escalate year over year which creates a significant burden on employers. Strategies that mitigate risk, such as member education around plan cost difference, product switching by providers and innovative benefit coverage, are more important than ever. If employers are serious about driving down costs, while ensuring their members have access to therapies that treat complex chronic, life threatening and rare medical conditions, this is the time to act on the use of biosimilars.
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Considering Authorized Generics
In collaboration, the Mid-American Coalition on Healthcare (MACHC) and the Midwest Business Group on Health (MBGH) publish this report to bring cost management strategies to employers to help as they manage pharmacy benefits. The brief examines authorized generics as a class of drugs, their impact on the marketplace and provide guidance to employers to help ensure AGs are covered under the pharmacy benefit. To control spending, employers should discuss AG coverage with their Pharmacy Benefit Manager or Pharmacy Benefit Administrator (PBM or PBA).
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Insulin Access and Affordability
Diabetes impacts more than 34 million people in the US. This chronic disease is a result of how the body processes glucose. When it goes untreated or is not treated properly it can lead to many other co-morbid diseases and illnesses. Today, between 10% - 20% of people with type 2 diabetes need insulin to control their blood sugar. However, all people with type 1 diabetes require insulin every day to survive – it is a matter of life or death. Cost and access are the biggest barriers for those in need of insulin. This brief shows employers ways they can alleviate access and cost for this important medication for those who require it.
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Why Employers Shouldn't Ignore Diabetes
Employers cannot afford to wait to address the costly disease of Diabetes. By 2030, the total cost of diabetes is predicted to be $622 billion – a 53% increase from today. With stakeholders working together, we can change the face of this disease. This brief shows employers the costs of the disease and how to address them.
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