Episode 34 – Clinical Checkup

Mike Stull (00:09) 

Hi, everyone, and welcome to this month’s episode of HR Benecast, your source for expert commentary and insights on current health benefits-related news and strategies. This is your host, Mike Stull.  

It’s really hard to believe we’re coming up on the end of the year already, another record year in new pharmacy spend for our coalition. Not only means growth in our purchasing power, but growth for our team as well. In 2022, we added 14 new team members across various functional areas. Today, we’re joined by one of those team members, Matt Harman, who serves as our vice president of clinical solutions. 

Matt and his team monitor, evaluate, and improve upon Employers Health’s PBM group purchasing program, really with the goal to ultimately help clients achieve better clinical outcomes, minimal disruption, and overall lower costs. Matt also started the Managed Care Pharmacy Residency at Employers Health, which has served as a pipeline for the growth of the clinical team. He also manages and executes the organization’s flu immunization program, which administers flu vaccines to thousands of individuals annually at their workplaces. Matt serves on a number of local boards and national advisory committees as well.   

Welcome back, Matt, and I figure we’ll just get right into it. Your team recently got back from the Academy of Managed Care Pharmacy, so AMCP, its Nexus Conference, where I’m sure presentations and conversations centered around the latest in managed care pharmacy. 

So, tell us a little bit about what the hot topics were and what employers should be watching for.  

Matt Harman (1:58) 

Sure thing. At first, thank you for having me, Mike. 

I’m honored to be here and for all the loyal listeners of the HR Benecast. It’s my second time. I think first time had 6 million views, and some say it was the best podcast of all time. 

So, glad to get the return invite and happy to provide some insight today to our employers listening.  

So yeah, AMCP was a great time having the clinical team there, meeting with different representatives from health plans and pharma, and really getting a lot of great insights we can share with our employers. A lot of hot topics, you know, centering around, you know, the legislative issues, really. 

It’s amazing how much legislation, both at the state and federal level, have impacted and got kind of entrenched within pharmacy compared to when I started here over nine years ago. So, from, you know, initiatives to ban copay maximizers and accumulators to, you know, how’s the Inflation Reduction Act going to impact certain things. So, I know, you know, some employers are concerned about that act and how it might impact things indirectly. Still remains to be seen. I think there’s some opinion that, you know, pharma does things wrong, but, you know, because there’s a fear that they may lose profits on the government side. How will they impact employers? But, I talked to that they’re going to make sure that they are treating things fairly. We’ll see how that plays out.  

Yeah, I mentioned copay programs. That was, I feel like, a few different sessions since there’s concerns from pharma. How is that going to impact their revenue? But I think they understand that it’s better to have patients on their drugs than not on them at all. So, I do see them lasting a little bit longer in the future than maybe initially thought, unless state legislative initiatives stop them altogether.  

There’s also big interest in just public health in general. There’s a great guest speaker talking about how, particularly for employers, vaccination rates have gone down and, you know, and not just because of, you know, COVID vaccines, but just universal childhood vaccinations. And I think, you know, those kids and preteens eventually become employees. So, you know, trying to reinforce the importance of immunization. 

And I know there has been some certain mistrust in the industry because of the changing, what all that has changed from a science perspective as we learn more about COVID. But, you know, the way I think about it, if I have a loved one that has cancer, we’re not going to give them the treatment from 60 years ago. We know that, you know, science progresses hopefully towards the truth and most effective products. So, you know, that’s kind of the way it goes. As we’ve learned more, you know, the guidelines and everything are updated in that regard. And guidelines have definitely been updated. 

That’s another big piece that we saw just, I think, clients, you know, we’ve experienced this growth in specialty spend. A lot of that’s because guidelines are now putting more of these biologic products at the forefront of either first or second line and trying to eliminate some of the step therapies because the evidence is just just there to better disease control and better outcomes. Now, unfortunately, it comes at a more expensive price. And I’m sure we’ll talk a little later about, you know, different strategies to control those. So those are some of the things that we have kind of gathered from the AMCP conference.  

Mike Stull (5:35) 

Very good. 

Sounds like it was a full slate of good topics. Anything else in the pharmacy benefit market, maybe in general, that your team has its eye on?  

Matt Harman (5:50) 

Well, I think the elephant in the room is biosimilars. 2023 has been a year that I feel like we’ve talked about for the last decade with the pending launch of Humira. 

And how will that play out? I think lesser talked about is Stelara. You know, that’s the number two drug in Employers Health book of business. And that potentially can have biosimilars in 2024 or 25 or so. 

And then you’re going to have a cascade of other biosimilars throughout this decade. So how will that play out? And so, we have good data on the medical benefit, but it’s actually a little easier to get biosimilars on the medical side of things. But, the pharmacy will be a little trickier as patients are more familiar from an injection side. You know, you’re getting that injectable pen. So, you know what it is versus a brand new version. We think about the medical benefit biosimilar. It’s just a different bag they’re hanging from an infusion standpoint. So, sometimes the patient doesn’t even know that they’re getting a biosimilar. So, from a patient disruption standpoint, is it the same needle side? Are you having the same pain from the injection just because of the constituents that make up that drug?  

So, you know, the launches of Humira, the first one in January, and then we’ll have quite a few in July and throughout the rest of 2023. Now that we have the formularies that have been released for the 2023, none are preferring biosimilars, which makes sense since there’s not one out in the marketplace. But, I don’t expect anything really make a move in late 23 either, just because of how, you know, rebate guarantees and everything they’ve set out. My hope is that we will have some for 2024, at least options for employers. You know, if you want to be a biosimilar friendly formulary, maybe take a hit on your special rebates, you can go that option and not. And then those that want to keep collecting rebates and don’t want to, you know, maybe have potential disruption to members, then you can go that route as well. So, we’ll kind of be pushing for that for our clients.  

I would say from a disruption standpoint, you know, there’s been over, you know, hundreds of studies from switching biosimilars to the reference product and back and forth all over the world. And none have found any clinical meaningful difference for patients. So, I wouldn’t, you know, I know there’s always concern of disruption standpoint and ensuring patients continue to receive their products without, you know, gaps in care. But I’m confident that the biosimilars that, when they eventually have access to them, will provide the same level of care and hopefully at a lower cost to our, both our clients and their plan participants.  

Mike Stull (8:37) 

Yeah, I think one of the things we talked about this week at an advisory board I was at was, you know, how consultants and it goes for us too as a coalition, but how consultants need to adjust their models to take into consideration, you know, biosimilars that may have a lower list price. 

And we know that, you know, at the end of the day, it really is a big math problem. And so, you know, we know that the higher rebated products are typically higher list price. So, if you have a biosimilar that’s a lower list price, say 20% lower in list price, but has a smaller rebate, how do you, how do you factor in the lower list price? The models today don’t necessarily do that. And so, I think that’s a big change that advisors and consultants and us as a coalition helping to structure our contract have to make sure that our analytics are ready to account.  

Matt Harman (9:45) 

A hundred percent. Yeah, that’s what we’re focused on. 

So, I would say Mike, you sound fantastic. Is it the mic you have there? I’m so jealous of what you have versus in my little setup here. So, I probably listen to the podcast. I hope I won’t hate my voice as much as possible. I think the highest level of self-love is appreciating your own voice. And so, I’m getting better at that, but it’s hard. So, I’ll try to, you know, I need to invest in a better mic so I can appreciate my own voice more. 

Mike Stull (10:15) 

Well, I will tell you that the microphone doesn’t help me appreciate my own voice. It actually might draw out some of the other imperfections. 

So, I mentioned in my intro, I mentioned the growth of our team and for the clinical team in particular. I remember, I remember interviewing Matt. So, when we hired him, he was a team of one. 

So up to eight now, exciting times. And, you know, the question becomes, what does that mean for our clients?  

Matt Harman (10:57) 

Yes. I don’t know if the loyal listeners know that Mike was my very first boss at Employers Health. So, that’s a fun trivia fact. So, yeah, very, very lucky that we have eight members on the team now. That means that, you know, a little less stress on our hands. I mean, just to be honest, I’ve had two panic attacks in my life. One was that, back five years ago when before we had anybody else, it was just me. And realizing there’s so much could be done here. You know, we have so many employers and wanting to be at every meeting and wanting to respond to every email in less than five minutes. But, you know, it got hard because we keep growing. And so, I’m very lucky that we’ve invested in our clinical team. 

We have varying, you know, all varying strengths, but they’re all great personalities and hard workers and all feel very lucky to be here. And just like I do as well. So, I know that what it means for our clients is that you should have more clinical representation in your meetings. Even if we’re not in a meeting, there’s, I’ll say, a very, very high likelihood that we’ve reviewed your data and providing maybe talking points to your client solutions, team member, or, you know, business development executive. If we’re, we’re trying to get more involved in implementations, you know, it’s hard with, you know, since the sales team keeps selling like wildfires. So, congrats to you, Mike, on another record sales year. 

It’s very fun to be a part of the growth and we’re trying to be more involved and give that unique perspectives that sometimes, you know, our PBM partners, their pharmacists can say things that are, I can’t say certain things that we can, just commenting on the general marketplace factors and understanding a complete picture. So yeah, I think it, we’re getting more hands-on data, hopefully providing more content from, you know, getting more communication out there from written and get out there for presentations. And I want to be more accessible to both our clients and their consultants and brokers. 

Mike Stull (12:57) 

One of the things that I always found in, in working with, with different pharmacists all across the country was, you know, depending on where you went to pharmacy school really had an impact on how you saw certain things. And so, I think it’s really neat just to see how our team has, you know, continued to develop with the diversity from both diversity of individuals that are, are part of the team, but also where they’ve gone to school. And so, you know, definitely some different strengths among all of the team members that are on, on the clinical. 

Matt Harman (13:36) 

Thank you. Yeah. I mean, diversity is a big focus of mine and the team to continue to provide opportunities for individuals and, you know, just different strengths. 

I mean, you know, we do those strengths finder and one of mine is, you know, arranging and finding individualization of the talents and, and organize them to the best capabilities. So, I think that’s, we’re starting to do that. I mean, every pharmacist is trained at the clinical advisor level, but now as they get past that residency, we’re seeing some take on more data roles, more take on more presentation type roles, development of different tools. And yeah, it’s exciting to see where we can go from here.  

Mike Stull (14:10) 

So, when you’re looking at data, you mentioned that what are you guys, what’s your team? I should say, what is your team specifically looking for when you go through a self-insured plans data? 

Matt Harman (14:25) 

Sure. So, you know, first, how’s the trend looking? Positive, negative, super, if it’s growing considerably or, you know, dropping considerably when the, what are the driving factors there? Is it one claimant, you know, super high costs, a specialty claimant, or is this an overall trend that can be, you know, explained for a variety of reasons, like I mentioned earlier, you know, the guidelines changing and some of the autoimmune spaces are really driving some of that growth in that area, or is this low value spend that can be managed from a utilization standpoint? So those are some of the things, and how do those, you know, rankings from a therapeutic class or top drug perspective compare to, you know, book of business and Employers Health as well as that PBM’s book of business. 

So, sometimes, you know, there’s a formulary change that really is, you know, drives something, you know, or, you know, these different brand over generic strategies sometimes will, you know, make data look a little funny. So being able to provide that insight and understanding is important, but, you know, I think some, we’re always looking at what’s the major trend drivers, and I’m trying to understand, put that together with what we know from our marketplace insights.  

Mike Stull (15:41) 

Yeah, and that’s, that is key, right? Again, back to the advisory board I was just at this week, you know, one of the complaints I heard was, you know, too often, you know, account managers from PBM’s in particular will come in, they have a stack of reports, and it literally is just reading numbers off of a page. 

And, and so I think one of the big things that our teams, whether it’s client solutions, but particularly pharmacy, because you have the context of, you know, why are these drugs being used in the first place? I mean, being able to tell the story and put context behind, here’s why this is happening, here’s why patients are taking these medications, and here’s why it’s important to you as the employer. I mean, that’s the differentiator of working with a team like ours versus just working with the PBM alone.  

Matt Harman (16:36) 

Yeah, yeah, absolutely. 

I mean, we try to give that insight to, you know, all right, you have this new specialty patient, this is super, you know, it seems concerning from a spin side of things, but think about what this drug is doing, both for that patient, that quality of life, and just from a caregiver, their whole family, you know, these conditions can have an impact on not just that patient, but the individuals surrounding them, and as well as from the medical cost side of things, you know, avoiding hospitalizations. And so that’s what these drugs are for. You know, sometimes pharmacy trend is not bad. It’s, you know, for blocking hospitalizations and, you know, multiple day stays, or, you know, a variety of different things that can really drive trend that sometimes we don’t focus on. You know, those medical benefit, you know, trend gross. So that’s why we, you know, we try to provide that insight and learn why this drug is priced the way it is. Why is it, you know, gaining in terms of like moving up the guidelines and prescribing patterns. 

Mike Stull (17:34) 

So, we talked about looking at data from an individual plan level. Also, I know we look at data across our entire book of business, which, as you mentioned, we continue to grow. 

It continues to become a larger and larger data set. We’ve developed, your team has developed several custom clinical strategies that a lot of our clients have put into place to try to get rid of some of the wasteful spending in pharmacy plans. So, I wonder if you could talk through a little bit about the process, how you go about identifying some of these strategies, but also a little bit about, maybe, what you’ve seen from those groups that have put them in place. 

Matt Harman (18:20) 

Sure. So yeah, the way I think about our creating custom strategies, I really fall into three buckets. So that’s creating our own custom strategies that completely are unique to the coalition. 

Then two would be enhancing the PBM’s criteria and looking and making sure, you know, looking at prior authorization rates and different, how that might, you know, different criteria plays in from a documentation versus attestation side of things. And then also understanding the trend data, you know, understand the data that you mentioned in our own book of business, as well as from a pipeline side of things. So, when you’re talking about custom strategies, we think about, there’s a lot in the generic space. So, I know if our clients have one, you know, have seen the various flavors of high-cost generics 3.0, we’ll have exciting news, breaking news on the pod that high-cost generics 4.0 is coming out in 2023. So very exciting stuff. Another flavor of that would be our expensive dosage forms, you know, think about those that have tablets versus capsules that may be at one’s five times more expensive than the other, but the same clinical difference. 

And we’ve tried to think about the patient in mind here, minimize disruptions as much as possible, because we understand how important that is to our clients. And we’ve customized the messaging at the point of sale, the pharmacy, to recommend the alternative that the pharmacist could, you know, call that physician or potentially have that alternative on the shelf and fill it right away to, you know, so that way that patient doesn’t leave the pharmacy and still, you know, get their care right away. So that’s one way. 

And in terms of our own, you know, criteria that maybe is similar to the PBMs, but sometimes PBM criteria is just checking for diagnosis and allows the doctor to just check a box. Well, think about some, you know, there’s a lot of medications, particularly in the dermatological space, that there’s generic alternatives that just work as fine. So, we’ll incorporate a step therapy into there, maybe require some documentation to ensure efficacy for a variety of different things. So, because some of the PBM criteria may have 80 plus, 90 percent plus approval rates. So, it’s something we evaluate on an annual basis, at least from our various PBM partners to see what approval rates are too high. Maybe we need to tweak a little more or just turn off altogether if it doesn’t make sense. 

Why are you subjecting clients to or patients to, you know, PAs if it’s ultimately going to be approved anyways? And then, as you mentioned, looking through the pipeline, encouraging PBMs to come up with criteria and have it in place. And sometimes we feel very strongly, hey, can we make this an opt-out approach where only if a client doesn’t want it, then they say, we don’t want to have this step therapy on these migraine medications. And they can turn that off rather than having them sign off on a form to adopt it. 

So, those are some of the ways we think about from a custom clinical edits. You know, looking forward to get more into the specialty spaces as things go along.  

Mike Stull (21:26) 

I love the breaking news on the podcast. Hopefully we have a good sound effect that we can breaking news.  

Matt Harman (21:40) 

Yeah, that’s what people would turn to tune in to learn things like that.  

Mike Stull (21:43) 

That’s right. We appreciate it.  

I know at our PBM conference, we had Rob O’Brien talk about gene therapies and what impact they may have on employers. Certainly, we know that some are out there. We know some are close. Anything new that you all have seen in terms of employers combating the risk associated with the price tag on some of these really novel, really exciting therapies?  

Matt Harman (22:18) 

Sure. At first, just to set the stage right now, there are four true gene therapies approved. 

You know, there’s different ways you can classify gene therapies. But the real true gene therapies, we have four. And one was in August and one was in September. So, we’ve doubled just in the last few months. And then I would think over the next year or two, we’re going to potentially triple. And a lot of those are going to be in the hemophilia space. 

Yeah, we can talk a little bit from a pipeline perspective. But from a solution perspective, I think it is challenging. You know, there’s different, either PBM or health plan programs, like these PMPM fees to hopefully minimize the risk. 

Now, I just haven’t seen the data. Like, how are those playing out? You know, and I know that and I think there are finally options. I think at least CVS has one you can pay out over time if you have a gene therapy coming about, but it’s really challenging from a warranty perspective, particularly in the employer space, or what happens if you pay for that gene therapy and that patient leaves a few years down the road. 

One of the groundbreaking gene therapies we’re going to have in the next year or so, hemophilia space, fantastic data. I mean, you’re talking 98% reduction in factor usage, you know, works really well, but it’s works about 90% of the time. So, what happens when you’re paying $3 million for that, you know, for 10% of the population doesn’t work? How does that play out from a warranty perspective? Or how does it play out if it didn’t fully work half as good? So, I think there’s still some challenges that we need to work out. 

Employers may be able to stand one gene therapy, but once you get a couple, you know, that those budgets are going to be tighter, harder to manage. So, I know stop loss has been a big, big piece of it. So, you know, I think there’s some new programs out there, but we haven’t seen them fully, you know, kind of utilize. 

I don’t know about, Mike, if you have, but there’s just been kind of the talk of here’s what the programs are. But, you know, in terms of enrollment and, you know, patient kind of satisfaction, client satisfaction, you know, reflections on those programs so far, I haven’t really seen just yet.  

Mike Stull (24:42) 

Yeah, I haven’t necessarily seen any major results. I think, you know, as we’ve done some quick math on some of them, you know, they just, they don’t seem to make a lot of sense as it relates to managing that risk. I think also you have to have a really big risk pool in order to effectively spread the cost out at a reasonable amount. And maybe that’s something that, you know, from a policy perspective, I know even large employers through some of the big surveys we’ve seen or that I’ve seen out in the marketplace, you know, have shown some interest in some sort of government risk pool. And so maybe that’s something that from a public policy perspective, we can turn our attention to as more and more of these become more commonplace.  

Matt Harman (25:34) 

Absolutely. You know, I know some of the manufacturers will offer if the drug doesn’t work and, you know, they haven’t done it for every single one, even within the same manufacturer. So, I think it’s interesting to see they’ll kind of put their money where their mouth is for some, but not others, which makes me a little concerned. It’s confusing. We only have four. 

Mike Stull (25:57) 

You hit on one new pipeline drug. Anything else from a pipeline perspective that you wanted to cover?  

Matt Harman (26:05) 

Sure. I’d say the growth in atopic dermatitis is something employers need to focus on. I think you may be familiar with the drug Dupixent, was really the first specialty product approved for that. Now we’ve had a few. So Adbry, RINVOQ, probably is the most heavily utilized, and CIBINQO. And we want to make sure that those drugs that there’s appropriate documentation of the level of atopic dermatitis, since there’s quite a few products that can be used as kind of step therapy piece of things and, you know, ensuring that those drugs are being effective. So, there’s a lot more to come on that atopic dermatitis side. It’s been a big focus.  

Orphan drugs are probably the largest piece from the pipeline. Almost 50%, which generally used to be cancer was 50%. Cancer is more than 20, 30% of the pipeline going forward. So, there’s been a huge focus on the orphan drug side, which makes it much more tougher to manage. You’re lacking therapeutic alternatives. Many of these patients don’t have any therapies out there currently. And so, they’re just waiting for approval. And so how will that play out? So also, I guess, on the specialty side, we’re going to see more in multiple sclerosis. 

I think it’s interesting that a lot of oral products, when the existing oral products, Tecfidera is already generic. Gilenya has been back and forth, you know, patent litigation, but that should be generic launching here any minute now. And Aubagio as well in the next year. 

So, I think having sound step therapy and control on the multiple sclerosis side will be important. But yeah, lots to come in the specialty pipeline. In terms of diabetes, I guess it’s worth mentioning. 

We’ll, I guess, a few years away from those products going, you know, the ones that are kind of in the top spin going generic. It’s tougher since a lot of them are injectable products. But who knows, by the time those go generic, there’ll probably be new ones that are out and at the top of spin. 

One thing I can think of is Mounjaro, you know, product that was approved this year for type 2 diabetes with outstanding data for diabetes as well as obesity. So, I expect that to be one of the top five drugs in the world once it’s all said and done. So, we’ll see how it plays out from a formulary side of things. 

It sounds like Eli Lilly’s not playing the rebate games as PBMs would like compared to some others. So interesting to see. So that’s kind of led to less adoption from a formulary side of things. Don’t penalize manufacturers for being good, right? Come on.  

Mike Stull (28:46) 

That’s right. That is right. 

All right. Well, I can tell already this is going to be an instant classic.  

Matt Harman (28:54) 

We’re going to pass 6 million listeners on this one? 

Mike Stull (28:58) 

 I think we might get there. 

All right. So, I think some would say this might be the new best podcast. So, I appreciate you sharing. Anything that we missed? I feel like we went top to bottom in terms of the list of topics we wanted to cover, but anything that we missed?  

Matt Harman (29:21) 

Oh, yeah, man. Yeah. Thank you all for listening. 

Thanks for Mike for having me. If there are any things that I mentioned and you have questions about, feel free to reach out. If you have my email, connect on LinkedIn. 

Happy to answer anything that you’d like further clarification on. So, hope to be back in the future.  

Mike Stull (29:41) 

And make sure you read the articles in the EH Connect and on the blog. 

Matt Harman (29:45) 

Absolutely. 

Mike Stull (29:48) 

 I know your team takes a lot of time and pride in putting together good information for those as well.  

Matt Harman (29:50) 

We try. 

Mike Stull (29:53) 

Yeah. It’s appreciated. All right. Thank you, Matt. 

Matt Harman (29:55) 

All right. Thank you all. Take care. 

Mike Stull (30:00)  

Before we go, I want to thank our sponsors for helping to not only make this podcast possible but for supporting us and in providing great employee benefits content throughout the year. Thanks to our annual supporters, CVS Health, Optum RX and Elixer and our executive supporters, Delta Dental, Para Theraputics, Pfizer and USRX Care.  Visit employershealthco.com/supporters for a full list of sponsors. 

If you haven’t already, be sure to save the date for our 2023 Pharmacy Benefits Conference that will be March 8th in Columbus, Ohio, where you will hear from members of our clinical team and other experts in pharmacy benefits.  Visit employershealthco.com/events to see all of our upcoming employee benefits events. 

Be sure to subscribe to HR Benecast to be notified when the latest episode is out. 

There is always something new at Employers Health so follow us on our social media, LinkedIn and Twitter to stay up to date. 

So that’s it for this month’s episode.  Thanks again to Matt and the entire Employers Health clinical team for their knowledge and dedication to our clients. 

Thank you for taking the time to listen and for your continued membership, participation and interest in Employers Health. 

Be well and see you soon.