PBMs Can Help Bend the Cost Curve: Express Scripts' Tim Wentworth

All eyes are currently on the 34th annual J P Morgan Healthcare Conference, one of the biggest global healthcare investors conference, being held in San Francisco, California. The meeting, being held January 12-15, brings leaders in the pharmaceutical and healthcare world as they showcase their pipelines and portfolios. Also leading the way are healthcare insurance giants and pharmacy benefit managers (PBM).

As the industry struggles to adapt to the growing demand of justifying the value of a product or service, payers and pharmacy benefit managers are negotiating indication or outcome-based pricing proposals with manufacturers. Leading the way is Express Scripts. According to president Tim Wentworth, the PBM “saved our clients more than $3 billion through the Express Scripts National Preferred Formulary and $2 billion through novel compound drug management solutions.” He was speaking on the evening of the first day of the Healthcare Conference.

Wentworth said the company has about 3000 clients and fills 1.3 billion prescriptions annually. “We are in a demanding time, but healthcare companies are innovating and we have to create the headroom for innovative companies,” to ensure patients have better access to revolutionary therapies, while at the same time reducing waste, Wentworth said.

He shared data highlighting the growing prescription trend, which saw a 13.1% growth rate in 2014—the highest in over 10 years. With hepatitis C and cancer leading the way, analysis showed that specialty drug trend more than doubled in 2014 and touched nearly 31%.

Explaining the position that his company took with the expensive hepatitis C drugs, Wentworth said, “We made a bold move with hepatitis C which supported patient access; but we did not take the same approach with PCSK9s (low-density cholesterol regulator). With this class of drugs, we have developed a program to give payers the confidence to access these drugs at an affordable cost.”

“Our motto,” Wentworth said, “is to combat excessive drug pricing, protect our clients from brand drug information, and create novel indication-based reimbursement.”

Touting their achievements in the past year, he said, “We have delivered a strong performance in 2015, and touched over 3000 clients. There are no claims lag in pharmacies, it’s all real-time. This challenge helps us build long-term solutions for our clients.”

Express Scripts, he said, has the following core areas of focus:

Core PBMs

With the high emphasis on drug pricing in 2015, Express Scripts’ formulary managers developed programs to ensure real access to patients. Wentworth was very vocal about the company’s belief in biosimilars as a lead to combat drug prices. “We have a real opportunity to create cost-savings with biosimilars. We will possibly be talking about a likely ‘biosimilars wave,’ similar to the ‘generics wave,’” he said.

Biosimilars have a 30% average discount in price in countries where they are available, which can significantly impact a drug’s market share. “We are well-positioned to execute on this for our payers, Wentworth said, adding that the PBM predicts a cost saving of $250 billion over a decade with just 11 biosimilars.

Specialty

Through their specialty pharmacy and service provider Accredo, Express Scripts has introduced SafeGuardRx solutions for oncology, hepatitis C, and cholesterol. These Value Programs are aimed to provide unique solutions with the recent wave of highly-priced products. Introducing their new approach Wentworth said payers can invest in a care model and integrate with PBMs to allow an approach where management, rather than dispensing, is the key. One innovative strategy being evaluated with the oncology program, for example, is indication-based pricing for cancer drugs.

Services and Home Delivery

Indicating the growth of mail-order pharmacy, Wentworth said, “Our job has been to reposition ourselves, to leverage the opportunity at hand. We have best positioned ourselves to capitalize on the retail-to-digital shift.” The PBM documented a 58% increase in retail to mail conversions in 2015.

“With our unique position we can easily partner with both payer and pharma. Full alignment with clients makes us the best PBM option.We are very confident with what we can deliver this year and beyond,” he concluded.