药品福利管理：最新PBM调查要点

1、Pharmacy Benefit ManagementTakeaways from Our Latest Proprietary PBMSurveyNorth America Equity Research11 December 2019We have conducted our 26th proprietary survey of HR executives at large employers across the U.S., helping us to gain a better understanding the current thoughts on key themes and t

2、rends related to pharmacy benefits. These responses build extensive industry knowledge gleaned various companies, consultants customers, as well as prior survey work conducted twice annually since 2007, allowing us to evaluate key trends time. We highlight key takeaways below and discuss in greater

3、detail in the report. We will host a call at 11am today, which will include a brief discussion of the findings and a roundtable discussion with benefit manager participants (contact your JPM salesperson fordetails).Broader Implications: While sentiment around the PBMs space remains weak, results aga

4、in present a challenging with 98% overall satisfaction and stable to improving service levels, while 70% believe PBMs are “part of the problem” (lack of transparency a common theme). PBMs continue to evolve, although respondents split on whether new integrated models will lower their overall healthc

5、are costs. Despite ongoing uncertainty around potential regulatory or market-driven changes, PBMs should broader macro trends opportunities around plan design that could also help drive improvingprofitability.CVS Health/Rx Channel (Lisa Gill) CVS continues to show high rates among customers and also

6、 rated well around perceived transparency. While still early in terms of pitching the integrated offering, we would expect this to be of a focus in the upcoming selling season for 2021 starts. Specialty remains the biggest concern for plan sponsors (CVS is the largest player), while a willingness of

7、 customers to implement preferred or narrow networks could drive incremental benefit to the companys retail business overtime.OptumRx/Express Scripts/Ingenio (Gary Taylor) OptumRx and Express satisfaction rates have generally trended weaker in recent years, seemingly inconsistent with the claimed hi

8、gh retention and 2020 script growth guidance. It encouraging to see near- majority belief in the potential of the integrated medical/pharma model, but it is not obvious that such offerings are yet moving share. ANTMs claims small mindshare at this juncture, but the survey indicates modest growth in

9、awareness vs the priorsurvey.Our survey focused several key areas, including: 1) the environment around rebates (still relatively low penetration around point-of-sale rebates, and broad customer interest in manufacturers moving to a net price model); 2) vertically integrated models (respondents were

10、 split as to whether integrated models can drive overall healthcare savings); 3) transparency (cited by respondents as one of the biggest concerns around the current PBM pricing model); 4) views on PBMs role as part the problem or the solution (given intense ongoing scrutiny around drug pricing and

11、the role of “middlemen,” an increasing them as part of problem); 5) satisfaction rates (which remain high despite views on the business model); 6) primary sources of potential disruption in the next five years (specialty and the regulatory environment the most frequently cited responses); and opport

12、unities around plan design (e.g., mail, specialty, formulary, retailnetworks).See page 39 for analyst certification and important disclosures.Healthcare Technology & DistributionLisa C. GillAC(1-212)622-6466 HYPERLINK mailto:lisa.c.gill lisa.c.gill Bloomberg JPMA GILL Michael Minchak, CFA (1-212)622

13、-6506 HYPERLINK mailto:michael.minchak michael.minchakAnne E. Samuel(1-212) 622-4163 HYPERLINK mailto:anne.e.samuel anne.e.samuel Managed Care/Facilities Gary P Taylor AC(1-212) 622-6600 HYPERLINK mailto:gary.taylor gary.taylorBloomberg JPMA TAYLOR Anthony Makdessi(1-212) 622-3682 HYPERLINK mailto:a

14、nthony.makdessi anthony.makdessiMichael Ha(1-212) 622-9009 HYPERLINK mailto:michael.ha michael.haJ.P. Morgan SecuritiesLLCJ.P.Morgandoesandseekstodobusinesswithcompaniescoveredinitsresearchreports.Asaresult,investorsshouldbeawaremay a of the of as a HYPERLINK / BackgroundWe have conducted our 26th p

15、roprietary survey of HR executives at large employers across the U.S., helping us to gain a better understanding of the current thoughts around key themes and trends related to pharmacy benefits. Surveys were fielded electronically by 50 respondents that are responsible for making benefit decisions

16、for leading U.S. companies (response rates varied slightly by question). In aggregate, the respondent companies comprised nearly 1.4 million U.S.-based beneficiaries and had aggregate annual drug spend of roughly $1.5 billion. The responses from this survey build on extensive industry knowledge we h

17、ave gleaned from various companies, consultants, and customers, as well as prior survey work conductedtwice annually since 2007 (which we believe provides for an interesting comparison and allows us to evaluate trends overtime).Broader ImplicationsIn our view, broader sentiment around the PBM space

18、remains weak, driven by uncertainty regarding the future of the current PBM business model. The latest survey results again present a challenging dichotomy, where 98% of respondents cited satisfaction with their PBM vendor, and 92% noted that service levels have been stable or improving, although a

19、majority believe PBMs are “part of the problem” as it pertains to rising drug costs (70% of respondents, up vs. prior surveys), with many citing a lack of transparency and an opaque business model. The PBM model continues to evolve, with larger players pursuing integrated models, although customers

20、were split on whether these combinations will lower their overall healthcare costs. And while value-based models can offer a way to align incentives, adoption remains relatively low, with respondents citing various hurdles to broader adoption. Despite ongoing uncertainty around potential regulatory

21、ormarket-drivenchanges that could impact the business model in the commercial market, PBMs could still benefit from broader macro trends as well as opportunities around plan design elements (specialty, mail, retail networks and formulary management) that could also help drive a tailwind to profitabi

22、lity.CVS Health/Rx Channel (Lisa Gill) CVS continues to show high satisfaction rates among its customers and also rated well around perceived transparency. While a relatively low percentage of respondents have seen companies outside of United/OptumRx pitching the integrated offering, we note that it

23、 is still early on in the Aetna integration, and we would expect this to be more of a focus in the upcoming selling season for 2021 starts. Specialty remains the biggest concern among plan sponsors over the next five years (CVS is the largest player), while a willingness of customers to implement pr

24、eferred or narrow networks could drive incremental benefit to the companys retail business over time.OptumRx/Express Scripts/Ingenio (Gary Taylor) Both OptumRx and Express satisfaction rates have generally trended weaker in recent years, seemingly inconsistent with the claimed high retention and 202

25、0 script growth guidance. It is encouraging to see near- majority belief in the potential of the integrated medical/pharma model, but it is not obvious that such offerings are yet moving share. ANTMs IngenioRx claims fairly small mindshare at this early juncture, but the survey indicates modest grow

26、th in awareness vs the prior survey.ConclusionsOur survey focused on several key areas, including: 1) the environment around rebates; 2) vertically integrated models; 3) transparency; 4) views on PBMs role as part of the problem or the solution; 5) satisfaction rates; 6) key concerns and sources of

27、potential disruption in the next five years; and 7) opportunities around benefit plan design. Below we provide several of the key takeaways.Rebates remain a key topic of interest. We note that 28% of respondents indicated that they would be most interested in changing terms around rebates the next t

28、ime their contract comes up for renewal or goes out to bid, slightly above the recent average. 43% of respondents indicated that their contracts allow the PBM to retain a portion of manufacturer rebates as part of the pricing structure, also slightly above the recent range. Point-of-sale rebates sti

29、ll showed relatively low penetration (28% of respondents indicated they have it, up vs. 21% in the prior two surveys), among those that dont currently have it, only 24% of respondents indicated plans to implement this in the future (down from 34% in our May-2019 survey). Of those that do not current

30、ly plan to implement point of sale rebates, many indicated a preference to receiving rebate dollars directly for the plan to use as it deems appropriate, and concern that point of sale rebates could lead to an increase in net costs to the plan. Interestingly, 51% of respondents pointed to a 20% or l

31、ess chance that pharma manufacturers shift to a net price model within 5 years (just 24% of respondents pointed to a probability over 40%). However, 82% of respondents indicated they would be in favor of a shift to that type of pricingmodel.Respondents were split on the ability of vertically integra

32、ted models to drive overall healthcare savings, which compared to the 58% of respondents in our May- 2019 survey that believed that integrated health insurer/PBM models have the potential to drive overall healthcare savings. Interestingly, only 33% of respondents have seen CVS or Express Scripts pit

33、ch the integrated offering in the marketplace despite now having that capability (although we note that it still remains relatively early). Despite each of the top five PBMs being owned or affiliated with large health plans, among those respondents that currently contract directly with their PBM ven

34、dor, there doesnt appear to be widespread demand to shift to carved-in relationships (36% of respondents pointed to a 0% probability of moving to a carve- in model under their health insurer in the next 3 years, with 36% citing a 1%-25% probability, and only 8% citing a 50% probability).Lack of tran

35、sparency was one of the most frequently cited concerns around the current PBM pricing model, with roughly 30% of respondents pointing to this.Other commonly-cited concerns centered on the rebate model and specialty drug costs. That said, we note that 63% of respondents indicated that they have or pl

36、an to move to a fully pass-through/cost-plus contract, while 37% still appear comfortable with the traditional pricing on PBM contracts. While we point to a small sample size and the potential for selection bias, we note that more respondents cited CVS Caremark as making the biggest efforts to impro

37、ve transparency as it relates to contracting and fees. Interestingly, when asked about spread pricing, which has garnered a significant amount of attention recently, especially in the Medicaid market, 33% of respondents indicated that their contract does allow for it, while 48% of respondents have a

38、 contract that does not allow it, and 19% dont know or arent sure.A higher percentage of respondents pointed to PBMs as part of the problem as it relates to higher drug costs than in previous surveys (70% of respondents in the latest survey, up from of respondents in May-2019 and 50% in December- 20

39、18). In our view, this isnt surprising, given the intense ongoing scrutiny around drug pricing and the role of “middlemen.” When asked why they believe that are a part of the problem, several respondents echoed broader concerns about the PBM pricing model (including lack of transparency), while othe

40、rs pointed to a conflicted business model and misaligned incentives (PBMs are in business to make money), and others noting that they believe PBMs dont add value. That said, those that believe PBMs are part of the problem, only 6% believe they could see lower net prescription drug spending without u

41、sing a PBM (some respondents cited direct negotiation). As a follow-up, when asked what PBMs could do to more effectively manage drug spend, respondents cited, among other things: pushing harder manufacturers for better rebates and discounts, increasing transparency, improving member engagement/outr

42、each, and better management of specialtyspend.That said, despite concerns around the PBM business model and transparency, satisfaction rates and service levels remain relatively high at the large PBMs. While customers continue to have concerns around how PBMs make money broadly, respondents do tend

43、to be happy with their vendor relationships. Overall, 64% of respondents indicated that they were “very satisfied” or “relatively satisfied” with their current PBM, which compares to an average of 67% in all of our surveys since 2007, while the overall satisfaction level remains consistent with leve

44、ls over the prior three years. While our sample size is relatively small, we view this as reassuring given the ongoing rhetoric in the press around the PBM business model.Importantly, we note that 92% of the survey respondents indicated that service levels have remained the same or improved over the

45、 past few years. We note that 22% of respondents cited a major service-related issue over the past two years, which is just slightly above the average over the previous six surveys.Specialty and government reform cited as the biggest sources of disruption, while Amazon was frequently mentioned as a

46、potential disruptive force. When asked what the biggest sources of potential disruption as it relates to Rx benefits, the most common responses were specialty utilization/costs (cited by 43% of the respondents) and government reform (cited by 33% of respondents). Interestingly, only 1 respondent cit

47、ed new entrants into the market. That said, when asked specifically which company/companies would be the most disruptive forces, 37% of respondents mentioned Amazon. Interest in the Health Transformation Alliance (HTA) still appears relatively low (just 3 of 48 respondents indicated that they were c

48、urrently a member of HTA, and while 75% of respondents indicated that they were aware of HTA, outside of current members, only 4 other respondents are considering joining it). If other organizations emerge with new initiatives focused on reducing prescription costs, it would likely take a relatively

49、 sizeable amount of savings for plan sponsors to be willing to shift away from their current PBM relationship (50% of respondents indicated they would need savings of more than 15%).We still see incremental opportunities around plan design options that could positively impact PBM profitability. With

50、 regard to mail, 86% of respondents either have mandatory mail or incentives to use mail, and 71% of those that dont would be willing to implement one of those in the future. 48% of respondents have a narrow or preferred retail pharmacy network, while 77% of respondents that do not indicated that th

51、ey would be willing to implement one in the future. 92% of respondents have adopted their PBMs standard formulary, with the majority of respondents (71%) pointing to little or no disruption. 64% of the survey respondentsindicated that they currently have a restricted specialty pharmacy network, and

52、of those that do not, 83% indicated that they would be willing to implement one in the future. Importantly, we are seeing willingness to use formularies in specialty categories (84% of respondents either have or would be willing to adopt a formulary design that excludes products in certain larger sp

53、ecialty categories where there are therapeutically equivalent products), while 58% of respondents have either already implemented or have discussed moving reimbursement of certain specialty drugs to the pharmacy benefit from the medical benefit.Full Survey ResultsRespondent BackgroundOur sample set

54、of 50 employers was national in scope and in aggregate represented a total of nearly 1.4 million U.S.-based beneficiaries, or roughly 27,715 per respondent, on average. Total aggregate annual drug spend was $1.5 billion. The respondents indicated an average drug spend of approximately $93 per member

55、 per month (PMPM), although we note a relatively wide range given the variation in the size of the group, member composition, etc. Respondents further indicated that drug spend per employee (PMPM), on average, increased 5% on a year-over-year basis (with traditional drugs relatively flat and special

56、ty drugs increasing roughly 12%).Current PBM Vendors and Satisfaction RatesWe note that 88% of the survey respondents indicated that they use either Express Scripts, CVS Caremark, or OptumRx as their vendor for PBM services, which was slightly was within the range we have seen in prior surveys over

57、the past few years where the top three have generally accounted for 70%-90% of respondents. In addition, two respondents use Prime Therapeutics, one respondent uses Cigna and one respondent uses IngenioRx (which is Anthems new PBM offering). Finally, we have grouped the two remaining respondents int

58、o the “other” category, which includes one respondent that uses Navitus (a smaller PBM that offers a transparent model), and another that uses MedTrak (a part of Rite Aids EnvisionRx PBM offering). Note that OptumRx is a subsidiary of UnitedHealth Group, which along with Cigna and Anthem, are all co

59、vered by J.P. Morgan Managed Care Analyst Gary Taylor.Figure 1: What Vendor Do You Use for PBM Services?n=5010211102112CVSCaremark17PrimeTherapeuticsOtherSource: J.P. Morgan Pharmacy Benefits Survey, December 2019.The majority of respondents contract directly with their PBM via a carve-out arrangeme

60、nt. Overall, 72% of respondents contract directly with their PBM via a carve-out arrangement. In looking at the respondents that have PBM services provided by either Express Scripts or CVS Caremark, 82% of those respondents contract directly with the PBM (through a carve-out arrangement), while the