05/17/2019
Kip, I appreciate your questions about my last week’s post regarding a single prescription drug formulary for MN; from which the MN MultiState Contracting Alliance for Pharmacy (MMCAP) could negotiate and leverage further price discounts; especially if their contracts w/ drug companies can be expanded to include MN’s uninsured and underinsured, and eventually all Minnesotans. Here is a link to MMCAP website. http://www.mmd.admin.state.mn.us/MMCAP/background/NewMemberInfo.aspx. MMCAP, in my experience, has been very supportive of MN communities’ efforts back in 1990s and now. As for DHS, different story, but the expansion of their public Formulary to now include managed care PMAP is one positive step.
MMCAP uniquely now contracts with drug companies for $1 billion in Rx and medical supplies for MN and 48 other states. So far the contracts are limited to state government subdivisions e.g. jails, student health, mental health, public hospitals, first responders..
Here are my answers to your questions:
Question. Does the Multistate Contracting Alliance for Pharmacy have a formulary? Is it substantially different from the Medical Assistance Preferred Drug list?
Currently MMCAP DOES NOT utilize a Rx drug list of only safest and most effective medications, a formulary. Yet MN Medicaid ( Medical Assistance, a public program administered by MN Dept of Human Services ( DHS) does utilize something close to a formulary; a Preferred Drug List (PDL). My suggestion to the Managing Director, Pharmacist, and Attorney from MMCAP, beginning Dec. 2017 in two conference calls followed by emails, was to utilize the already existing MN Medical Assistance public formulary (PDL). A drug formulary is a powerful tool in leveraging and negotiating prices with drug companies. Here are a few key points as to why this makes sense:
MN Medicaid’s public formulary and nearly all aspects of their pharmacy benefit management are in-house, not contracted out to a PBM company middleman.
Question. Do you know if any legislation has ever been introduced in MN to do what OR and WA have done -- add their uninsured to the residents for whom the alliance purchases drugs?
Regarding expansion of MMCAP to include the uninsured and underinsured; according to MMCAP attorney, Justin Kaufman, such expansion likely doesn’t require legislation since MN Statute 471.59 sub 1, joint powers agreement, states that entities can enter into agreements for shared services. This means, however, that MMCAP would have to find a nonprofit sponsor on behalf of MN’s un/underinsured to share in the contract. Other states, I’m told, such as NY do this. Any suggested NPs from this list serve are welcome ? To be sure, Alan Dahlgren, Managing Director, and Sarah Turnbow, Pharmacist, flew out to both WA and OR to study their programs.
Question: “What is your impression of the Medical Assistance Preferred Drug List that you linked to?”https://mn.gov/dhs/assets/preferred-drug-list-fee-for-service_tcm1053-292127.pdf I scanned it and noticed that for most categories of drugs the number of "non-preferred" drugs exceeds the number of "preferred" drugs, and in many cases the gap is considerable.”
The PDL, which contains both “Preferred” and “Non-preferred” drugs is not a true formulary, but it is as close as we can get, and there is no contracting out to a PBM as is the case with nearly all private insurers (unless the insurer bought-up the PBM). The non-preferred drugs are, essentially, a back door approach for drug companies to sell their higher-priced drugs. The non-Preferred drugs do require Prior Authorization, which in itself is a huge barrier to continuity of care. MN Statute 256B.0625 beginning with subdivision 13, p.11. describes it: https://www.revisor.mn.gov/statutes/cite/256B.0625/pdf It uses the term “drug formulary” but “Preferred drug list” used later is more accurate. The PDL, rather than a true drug formulary, happened under OBRA 1990. Before 1990, Medicaid, like Medicare, was prohibited from negotiating drug prices on behalf of their tens of millions of enrollees. That changed under OBRA 1990 which required drug companies to give significant rebates on their drug prices to state Medicaid programs. The trade off was state Medicaid programs had to give up their restrictive drug formularies (restrictive in a good way), given the unrelenting marketing by drug companies.
Question. What are the criteria used to make these distinctions, and do you trust (a) the research that the formulary committee presumably relied on and (b) the judgement of the formulary committee?
The criteria are described in the link above e.g. establishment and composition of a “drug formulary committee”, also “drug utilization review” process. Some of these processes are subject to “public hearings.” I have no doubts that drug companies and their allies could infiltrate these processes, as they do the very drug approval process itself within the FDA. Counteracting this possibility, however, is pharmacists, Pharm.D.s, whom since 2010 are reimbursed for direct patient care via comprehensive medication reviews, “Medication Therapy Management” as described in the same link above. When I do MTM workups I attempt
to discontinue all unnecessary and superfluous
expensive medications a patient takes, leaving only safest, most effective and least expensive meds.
Question. There are, for example, two preferred drugs on the Alzheimer's list (two versions of the same drug, apparently) and two non-preferred (also two versions of what appears to be the same drug). I'm vaguely aware of the literature on Alzheimer's drugs. None of them have been shown to work very well. Would you agree with that? If that's the case, is it really helpful to exclude two of the four drugs? Were the two excluded drugs excluded because their manufacturer wanted a king's ransom for them? Because the research shows they are less effective or have worse side effects?
Show Quoted Content
Question. There are, for example, two preferred drugs on the Alzheimer's list (two versions of the same drug, apparently) and two non-preferred (also two versions of what appears to be the same drug). I'm vaguely aware of the literature on Alzheimer's drugs. None of them have been shown to work very well. Would you agree with that? If that's the case, is it really helpful to exclude two of the four drugs? Were the two excluded drugs excluded because their manufacturer wanted a king's ransom for them? Because the research shows they are less effective or have worse side effects?
I agree, the Alzheimer’s meds are only marginally effective based on before and after questionnaires administered to patients or patient or caregiver observation. No breakthroughs as yet. (Also, most supplements haven’t been studied enough to know for sure whether they work for improving memory or prevention). Regarding the two versions of Donepezil on the Preferred list, one is a tablet, the other is ODT (orally disintegrating tablet), so that makes sense, as does mementine, which has a different mechanism of action. All the ones on the non-Preferred list are not only duplicative ( same mechanism of action, but often the more expensive brand name version, or extended release, transdermal, etc, which are all very expensive and address no more effective. If it were a true formulary, these would be largely excluded, and maybe one or two prior authorized.
Joel
Joel M. Albers, Ph.D., Pharm..D.
Health Economist
Co-op Care, an initiative of
Universal Health Care Action Network of MN
501(C)(3)
Clinical Pharmacist
West Bank Pharmacy and Walk-in Clinic
612-384-0973
On May 7, 2019, at 6:10 AM, Kip [email protected] [MN_SP] wrote:
Joel, I really enjoyed reading your report on your suggestions to Keith and the new drug commission. Could you elaborate on two of your suggestions?
Your first suggestion is to create a single MN formulary. Your second was to expand the MN Multistate Contracting Alliance for Pharmacy to include all uninsured.
I have always been just a bit worried about formularies of any kind, but I also realize formularies give nations and states some leverage over PBMs and drug companies they wouldn't otherwise have. (Of course, they give insurance companies leverage too.) So I have always accepted formularies as a necessary pain in the butt.
My concern has always been that formulary committees must work in the dark -- we have so little research comparing one drug to another.
What is your impression of the Medical Assistance Preferred Drug List that you linked to?https://mn.gov/dhs/assets/preferred-drug-list-fee-for-service_tcm1053-292127.pdf I scanned it this morning and noticed that for most categories of drugs the number of "non-preferred" drugs exceeds the number of "preferred" drugs, and in many cases the gap is considerable -- the number of preferred drugs is substantially smaller than the excluded (non-preferred) drugs.
What are the criteria used to make these distinctions, and do you trust (a) the research that the formulary committee presumably relied on and (b) the judgement of the formulary committee?
There are, for example, two preferred drugs on the Alzheimer's list (two versions of the same drug, apparently) and two non-preferred (also two versions of what appears to be the same drug). I'm vaguely aware of the literature on Alzheimer's drugs. None of them have been shown to work very well. Would you agree with that? If that's the case, is it really helpful to exclude two of the four drugs? Were the two excluded drugs excluded because their manufacturer wanted a king's ransom for them? Because the research shows they are less effective or have worse side effects?
Does the Multistate Contracting Alliance for Pharmacy have a formulary? Is it substantially different from the Medical Assistance Preferred Drug list? Do you know if any legislation has ever been introduced in MN to do what OR and WA have done -- add their uninsured to the residents for whom the alliance purchases drugs?
I hope I'm not asking questions that require a lot of research on your part.
Thanks.
Kip
From: [email protected] [mailto:[email protected]] On Behalf Of Joel Albers [email protected] [MN_SP]
Sent: Wednesday, May 01, 2019 7:35 PM
To: [email protected]; [email protected]; [email protected]
Subject: [MN_SP] Reportback:Mtg w/ AG Ellison; Solutions to Rx Drug Price Crisis
Two weeks ago I met with MN attorney general Keith Ellison, and his Chief of Staff, Donna Cassutt, (both of whom I've known since early 2000s). Here are four key, feasible, low implementation cost, administratively efficient solutions to the Rx drug pricing crisis at the state level which I recommended. I met with Keith 1 week before the first mtg of the AG Task Force for Lowering Prescription Drug Prices as I was unable to attend.. Best solution to the Rx drug price crisis is obviously a single-payer system (federal or state) or allowing Medicare to negotiate Rx drug prices for all 45 million or so Medicare beneficiaries.
Here are four state-level key Recommendations:
1.Establish one MN state drug formulary:
This would replace the multiple, onerous, private HMO formularies. (The companion to a single-payer is a single-formulary,list of only safest, most effective medications). That's first key step. Other recommendations follow from that. MN Medicaid's fee-for-service sector (public,non-managed care) already has a drug formulary. It's called the "Medical Assistance Preferred Drug List" and is a great starting point:https://mn.gov/dhs/assets/preferred-drug-list-fee-for-service_tcm1053-292127..pdf
In addition, starting July 1, 2019, all contracted out private Managed care drug formularies for public programs will use MN F-F-S public formulary and be referred to as: "Minnesota Fee-for-Service and Managed Care Medicaid Uniform Preferred Drug List effective July 1, 2019". Technically HMOs will still have a formulary, but the default will be MN public Medicaid's PDL.
Here is a further description:
"Managed Care Organizations (MCOs) that offer drug benefits to Minnesota Health Care Programs (MHCP) members must use the Minnesota Department of Human Services' (DHS) Uniform PDL beginning July 1, 2019. The Uniform PDL will ensure a more consistent drug benefit for all members and minimize disruptions if a member's health plan changes. The Uniform PDL was reviewed and recommended by the Drug Formulary Committee and includes many commonly used medications. Members enrolled with an MCO will have access to all of the preferred drugs on the PDL as well as the other drugs on their plan's List of Covered Drugs (formulary). This change does not apply to members with dual Medicare and Medicaid coverage." Nevertheless, this marks progress toward an eventual public state formulary for all Of MN.
2.Expand already existing MN Multistate Contracting Alliance for Pharmacy (MMCAP) to include all uninsured:
Since 1985, MN Multistate Contracting Alliance for Pharmacy (MMCAP), division of MN Dept of Administration,has administered a purchasing pool combining the purchasing power of 5,000 separate facilities from 49 state governments (higher education facilities, hospitals, prisons, first responders, counties, cities and school districts, to buy more than $1 billion per year in Rx drugs, medical supplies,influenza vaccines, dental supplies, and drug testing equipment.
This could be expanded to include all uninsured Minnesotans and those on high deductible insurance. Oregon and Washington already do this. Oregon receives 50% off list prices for brand name drugs and up to 80% discounts for generics.
3.Reinstate MN DHS Program and website for Rx Importation from Canada, England:
"Rx MN Connect: Affordable Prescription Medicine from Canada." (and England). www.MinnesotaRxConnect website was successful before being inactivated after Medicare Part D Rx drug benefit was established in 2003. The AG said he would request Jim Canaday, Deputy AG (and pharmacist), to research the legalities of reactivating the website.
4.Potential for Importation from Canada, England, Europe via U.S. wholesalers to U.S. retail pharmacies:
VT enacted the first time ever in the U.S. Rx wholesale importation 2018. It "creates a wholesale importation program to purchase high-cost drugs through authorized wholesalers, who will purchase the drugs in Canada and make them available to Vermonters through an existing supply chain that includes local pharmacies." https://nashp..org/vermont-legislature-first-in-the-nation-to-approve-rx-drug-importation-from-canada/
Happy Mayday, and hope to see folks this sunday at the Mayday Parade where HCFA-MN will be marching for Medicare for All. My 11 yr old daughter, her friends, myself and UHCAN-MN folks will participate as cheerleader "Mad as Hell" doctors and nurses with scrubs etc. See you in the streets,
Joel
Joel M. Albers, Ph.D., Pharm.D.
Health Economist
Co-op Care, an initiative of
Universal Health Care Action Network of MN
501(C)(3)
Clinical Pharmacist
West Bank Pharmacy and Walk-in Clinic
612-384-0973
Show Quoted Content
Joel, I really enjoyed reading your report on your suggestions to Keith and the new drug commission. Could you elaborate on two of your suggestions?
Your first suggestion is to create a single MN formulary. Your second was to expand the MN Multistate Contracting Alliance for Pharmacy to include all uninsured.
I have always been just a bit worried about formularies of any kind, but I also realize formularies give nations and states some leverage over PBMs and drug companies they wouldn't otherwise have. (Of course, they give insurance companies leverage too.) So I have always accepted formularies as a necessary pain in the butt.
My concern has always been that formulary committees must work in the dark -- we have so little research comparing one drug to another.
What is your impression of the Medical Assistance Preferred Drug List that you linked to?https://mn.gov/dhs/assets/preferred-drug-list-fee-for-service_tcm1053-292127.pdf I scanned it this morning and noticed that for most categories of drugs the number of "non-preferred" drugs exceeds the number of "preferred" drugs, and in many cases the gap is considerable -- the number of preferred drugs is substantially smaller than the excluded (non-preferred) drugs.
What are the criteria used to make these distinctions, and do you trust (a) the research that the formulary committee presumably relied on and (b) the judgement of the formulary committee?
There are, for example, two preferred drugs on the Alzheimer's list (two versions of the same drug, apparently) and two non-preferred (also two versions of what appears to be the same drug). I'm vaguely aware of the literature on Alzheimer's drugs. None of them have been shown to work very well. Would you agree with that? If that's the case, is it really helpful to exclude two of the four drugs? Were the two excluded drugs excluded because their manufacturer wanted a king's ransom for them? Because the research shows they are less effective or have worse side effects?
Does the Multistate Contracting Alliance for Pharmacy have a formulary? Is it substantially different from the Medical Assistance Preferred Drug list? Do you know if any legislation has ever been introduced in MN to do what OR and WA have done -- add their uninsured to the residents for whom the alliance purchases drugs?
I hope I'm not asking questions that require a lot of research on your part.
Thanks.
Kip
From: [email protected] [mailto:[email protected]] On Behalf Of Joel Albers [email protected] [MN_SP]
Sent: Wednesday, May 01, 2019 7:35 PM
To: [email protected]; [email protected]; [email protected]
Subject: [MN_SP] Reportback:Mtg w/ AG Ellison; Solutions to Rx Drug Price Crisis
Two weeks ago I met with MN attorney general Keith Ellison, and his Chief of Staff, Donna Cassutt, (both of whom I've known since early 2000s). Here are four key, feasible, low implementation cost, administratively efficient solutions to the Rx drug pricing crisis at the state level which I recommended. I met with Keith 1 week before the first mtg of the AG Task Force for Lowering Prescription Drug Prices as I was unable to attend.. Best solution to the Rx drug price crisis is obviously a single-payer system (federal or state) or allowing Medicare to negotiate Rx drug prices for all 45 million or so Medicare beneficiaries.
Here are four state-level key Recommendations:
1.Establish one MN state drug formulary:
This would replace the multiple, onerous, private HMO formularies. (The companion to a single-payer is a single-formulary,list of only safest, most effective medications). That's first key step. Other recommendations follow from that. MN Medicaid's fee-for-service sector (public,non-managed care) already has a drug formulary. It's called the "Medical Assistance Preferred Drug List" and is a great starting point:https://mn.gov/dhs/assets/preferred-drug-list-fee-for-service_tcm1053-292127..pdf
In addition, starting July 1, 2019, all contracted out private Managed care drug formularies for public programs will use MN F-F-S public formulary and be referred to as: "Minnesota Fee-for-Service and Managed Care Medicaid Uniform Preferred Drug List effective July 1, 2019". Technically HMOs will still have a formulary, but the default will be MN public Medicaid's PDL.
Here is a further description:
"Managed Care Organizations (MCOs) that offer drug benefits to Minnesota Health Care Programs (MHCP) members must use the Minnesota Department of Human Services' (DHS) Uniform PDL beginning July 1, 2019. The Uniform PDL will ensure a more consistent drug benefit for all members and minimize disruptions if a member's health plan changes. The Uniform PDL was reviewed and recommended by the Drug Formulary Committee and includes many commonly used medications. Members enrolled with an MCO will have access to all of the preferred drugs on the PDL as well as the other drugs on their plan's List of Covered Drugs (formulary). This change does not apply to members with dual Medicare and Medicaid coverage." Nevertheless, this marks progress toward an eventual public state formulary for all Of MN.
2.Expand already existing MN Multistate Contracting Alliance for Pharmacy (MMCAP) to include all uninsured:
Since 1985, MN Multistate Contracting Alliance for Pharmacy (MMCAP), division of MN Dept of Administration,has administered a purchasing pool combining the purchasing power of 5,000 separate facilities from 49 state governments (higher education facilities, hospitals, prisons, first responders, counties, cities and school districts, to buy more than $1 billion per year in Rx drugs, medical supplies,influenza vaccines, dental supplies, and drug testing equipment.
This could be expanded to include all uninsured Minnesotans and those on high deductible insurance. Oregon and Washington already do this. Oregon receives 50% off list prices for brand name drugs and up to 80% discounts for generics.
3.Reinstate MN DHS Program and website for Rx Importation from Canada, England:
"Rx MN Connect: Affordable Prescription Medicine from Canada." (and England). www.MinnesotaRxConnect website was successful before being inactivated after Medicare Part D Rx drug benefit was established in 2003. The AG said he would request Jim Canaday, Deputy AG (and pharmacist), to research the legalities of reactivating the website.
4.Potential for Importation from Canada, England, Europe via U.S. wholesalers to U.S. retail pharmacies:
VT enacted the first time ever in the U.S. Rx wholesale importation 2018. It "creates a wholesale importation program to purchase high-cost drugs through authorized wholesalers, who will purchase the drugs in Canada and make them available to Vermonters through an existing supply chain that includes local pharmacies." https://nashp..org/vermont-legislature-first-in-the-nation-to-approve-rx-drug-importation-from-canada/
Happy Mayday, and hope to see folks this sunday at the Mayday Parade where HCFA-MN will be marching for Medicare for All. My 11 yr old daughter, her friends, myself and UHCAN-MN folks will participate as cheerleader "Mad as Hell" doctors and nurses with scrubs etc. See you in the streets,
Joel
Joel M. Albers, Ph.D., Pharm.D.
Health Economist
Co-op Care, an initiative of
Universal Health Care Action Network of MN
501(C)(3)
Clinical Pharmacist
West Bank Pharmacy and Walk-in Clinic
612-384-0973
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Posted by: Joel Albers
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