Latest / Becker’s Payer Issues Podcast / GLP-1 Coverage, Affordability, and Member Access with Angel Ballew

Transcript

GLP-1 Coverage, Affordability, and Member Access with Angel Ballew · Becker’s Payer Issues Podcast

0:01
- The payer provider relationship has never been simple,
0:04
- but what's happening now is something different.
0:07
- Value based models are maturing unevenly,
0:10
- prior authorization reform is reshaping workflows on both
0:13
- sides, and affordability
0:15
- pressure is intensifying.
0:17
- The organizations that figure out how to collaborate
0:19
- genuinely, not just contractually,
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- are the ones that will set the terms
0:23
- for what comes next.
0:24
- Becker's fifth annual fall payer issues roundtable brings
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- together more than 500 executive level attendees and
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- 70 plus speakers for two days of focused
0:33
- senior level conversation on benefit design, network strategy,
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- transparency,
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- and the financial and regulatory dynamics that are
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- redefining how care gets paid for. Join us
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- November second and third at the Swiss Hotel
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- Chicago.
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- For the agenda and event details, visit beckerspayer.com
0:50
- and click on the events tab in the
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- upper right.
0:54
- Hello, everyone. This is Jacob Emerson with the
0:56
- Becker's Payer Issues podcast.
0:59
- Thrilled today to be joined by Angel Belew,
1:01
- who serves as the head of pharmacy clinical
1:03
- programs and services
1:05
- at Centene.
1:06
- Angel, thank you so much for taking the
1:08
- time to be with me on the podcast
1:09
- today. Thank you, Jacob. Happy to be here.
1:12
- Yeah, Angeline. We're glad to have you with
1:14
- us. Excited to dive into a topic that
1:16
- seems to be taking up, headlines every day
1:19
- at this point. But before we dive into
1:20
- all that, can you first,
1:22
- tell our audience a little bit more about
1:24
- yourself, your background in health care, and what
1:26
- it is that you do today at Centene?
1:30
- Absolutely. So I am a licensed pharmacist
1:34
- and have been in this space for close
1:36
- to twenty years
1:37
- with,
1:38
- close to seventeen of them being in the
1:40
- managed care space. And
1:42
- delighted to day be sitting in the seat
1:44
- that leads, our clinical services and programs here
1:48
- at Centene in the pharmacy department.
1:50
- And in that role, I have the opportunity
1:52
- to,
1:54
- not only see medications that are coming in
1:56
- the pipeline through drug information,
1:58
- but also service our members through,
2:01
- services like medication therapy management
2:04
- and quality and clinical programs,
2:06
- all while anchoring that in,
2:09
- big design work for our Medicare plans. So
2:12
- do a little bit of everything here at
2:14
- Centene as it relates to the clinical
2:17
- services
2:18
- within the Centene pharmacy services department,
2:21
- and I'm happy to be here today to
2:23
- talk with you about GLP ones.
2:26
- Yeah. Well, I'm glad you got us started
2:28
- on on kicking that off, Angel.
2:31
- Let's let's talk about how Centene is approaching
2:34
- GLP one coverage policy right now because
2:37
- it seems like
2:38
- like I mentioned when we started our conversation,
2:40
- it's a topic that dominates the headlines pretty
2:43
- much daily at this point. And as you
2:45
- know, it's a very rapidly evolving landscape out
2:48
- there in terms of coverage policies
2:51
- across markets, across different health plans.
2:53
- And Centene, of course, operates in several different
2:56
- health insurance markets. So
2:58
- how is the company
3:00
- approaching
3:01
- GLP one coverage policy right now across your
3:03
- your Medicaid, your Medicare Advantage, and your marketplace
3:07
- lines of business?
3:09
- Sure. I think one of the biggest things
3:11
- to understand is that really we don't have
3:13
- a single GLP one coverage policy across Ascentine.
3:17
- As you mentioned, we,
3:19
- service a really diverse population across Medicaid, Medicare,
3:23
- and marketplace.
3:24
- And so our approach really depends on which
3:26
- line of business we're talking about.
3:29
- No matter what line of business though, really
3:32
- our goal is consistent. We certainly want our
3:34
- coverage decisions to reflect the best
3:37
- available clinical evidence, which as you stated changes
3:40
- rapidly.
3:41
- And we want that to our clinical evidence
3:44
- to support,
3:45
- appropriate clinical use
3:47
- and address the unique needs of those patient
3:49
- populations.
3:51
- So if we start with Medicaid,
3:53
- those coverage decisions are heavily influenced by state
3:57
- specific requirements.
3:59
- There's a lot of
4:00
- flexibility,
4:01
- in those given state made Medicaid agencies
4:05
- have significant discretion
4:07
- over medication coverage,
4:09
- and that's no different in really obesity
4:12
- medication coverage.
4:13
- So some of our Medicaid states cover GLP
4:16
- ones for weight management and others do not.
4:19
- And then some may apply
4:21
- very specific utilization management criteria,
4:24
- and others leave that a little wide open.
4:27
- And so, really, our Medicaid approach has to
4:30
- balance that clinical evidence,
4:32
- our member needs, and then align to those
4:34
- state benefit requirements.
4:36
- You mentioned,
4:37
- Medicaid Medicare Advantage, and we also have a
4:40
- stand alone PDP product as well. And
4:43
- that coverage
4:45
- in that product line is really shaped by
4:47
- CMS guidance and federal requirements.
4:50
- So, historically,
4:51
- there's been a lot of important distinctions
4:54
- between covering obesity medications
4:57
- in this space versus,
5:00
- coverage for the same medication if there's FDA
5:02
- approved indications.
5:03
- So in this instance with GLP ones, type
5:06
- two diabetes, or cardiovascular
5:09
- risk reduction.
5:10
- And so as the evidence though continues to
5:13
- evolve
5:14
- and with recent developments like the Medicare Bridge
5:16
- Program, which just launched on the first of
5:19
- this month, actually,
5:20
- we're needing to kinda continually
5:22
- evaluate in this Medicare Advantage space how our
5:26
- coverage strategies might change over time while continuing
5:29
- to support appropriate access for members.
5:32
- And then in our marketplace
5:34
- business, we certainly evaluate coverage through a clinical
5:37
- lens, as I've mentioned in the other product
5:39
- lines as well,
5:41
- member access, regulatory requirements, and affordability.
5:44
- So
5:45
- it really all comes down to that there's
5:47
- not really a one size fits all approach,
5:50
- and that's intentional
5:51
- because we need to be really thoughtful
5:54
- around our application of these clinical policies
5:57
- dependent on which product line we're talking about
6:00
- to make sure that we're not only servicing
6:03
- our members
6:04
- appropriately,
6:05
- but also
6:07
- remaining responsive
6:09
- to any specific regulatory,
6:12
- nuances that come along with those product lines.
6:15
- Understood. And I I appreciate you breaking that
6:17
- all down for us, Angel. And it's a
6:19
- great call out that this all really depends
6:21
- on, the market you're talking about,
6:24
- and then a lot of this is shaped
6:25
- by by your government partners, that you work
6:28
- with, in in the Medicaid and the Medicare
6:30
- space. So fully understand that.
6:32
- I wonder, you know, when we're speaking with
6:34
- health plan leaders like yourself across the country,
6:37
- we're also hearing right now about the the
6:40
- financial burdens that this drug class presents,
6:43
- to a lot of plans right now and
6:45
- how they kind of,
6:46
- weigh,
6:47
- coverage policies. And so I wonder if you
6:50
- could break down for us how Centene is
6:53
- balancing,
6:54
- utilization
6:55
- management of GLP ones while still ensuring
6:58
- appropriate access for your members who who meet,
7:01
- the clinical criteria
7:03
- that that you've set.
7:05
- Certainly. And when we think about utilization management,
7:08
- I always think it's really important for us
7:10
- to start with the why, really. You know,
7:12
- why does it exist in the in the
7:13
- first place? And
7:15
- we certainly view utilization management as a
7:19
- clinical decision support framework rather than any type
7:22
- of, you know, restrictive
7:24
- tool. We we wanna allow access for these
7:26
- medications, particularly GLP one therapies,
7:29
- and that means we need to ensure that
7:31
- right the right patients are receiving
7:33
- the right treatment at the right time, really
7:36
- based on whatever the best available clinical evidence
7:38
- is is the time.
7:40
- And prior authorizations can be one of those
7:42
- primary tools that we use in this space,
7:44
- and in fact, it is the one that
7:46
- we use the most frequently
7:48
- in determinations of
7:50
- coverage. Certainly, we design
7:52
- our clinical policies to ensure that members are
7:55
- meeting that clinical criteria based on FDA approved
7:58
- indications,
7:59
- accepted clinical guidelines, and then certainly the,
8:02
- benefit requirements like we talked about in your
8:04
- previous questions
8:06
- question which is really tied to a product
8:08
- line.
8:10
- We sometimes use step therapy, although a lot
8:12
- less frequently.
8:13
- And, again, that would just be utilized with
8:16
- a goal of encouraging
8:18
- appropriate sequencing. So
8:21
- can we try one medication that is,
8:24
- less costly before
8:26
- we try the next one so that we
8:27
- can, you know, preserve access to the advanced
8:30
- treatments, which sometimes are a little more costly
8:32
- when they're medically necessary.
8:35
- I would wanna call out here, you know,
8:37
- this
8:38
- therapeutic class really has been changing very rapidly.
8:42
- And so at Centene, we recognized early on
8:44
- that this space would evolve, and so,
8:48
- we have developed a multidisciplinary
8:50
- work group, you know, specifically looking at this
8:53
- drug class, not only to look at the
8:55
- clinical evidence that's coming out, but also
8:58
- how do we monitor our utilization management techniques
9:01
- to make sure that we're not preventing access
9:03
- to care, but also, you know, remaining very
9:05
- diligent about the clinical appropriateness of care in
9:08
- this space. And so, really, as new data,
9:11
- new science becomes available and these treatment guidelines
9:14
- evolve,
9:14
- will evolve our utilization management techniques,
9:18
- as well.
9:20
- Absolutely. So for for you all, it's it's,
9:23
- focusing
9:24
- on right treatment at the right time. Tools
9:26
- like Prior auth, step therapy,
9:29
- can be really key here for for that.
9:31
- And I wonder, Angel, you know, we've also
9:33
- heard from
9:34
- insurance companies putting out their own research in
9:37
- this space,
9:38
- talking about some of the adherence challenges
9:40
- with this with this drug class,
9:43
- often finding that a a large chunk of
9:45
- individuals prescribed these medications
9:47
- don't end up re reaching a clinical clinically
9:50
- meaningful benefits.
9:52
- And so I wonder if you could explain
9:54
- for us some of the biggest adherence challenges
9:56
- that Centene is seeing among your members prescribed
9:59
- GLP ones,
10:00
- and then what some of the other clinical
10:03
- programs or innovations that your pharmacy teams are
10:06
- using to address these issues?
10:09
- Absolutely. So I think one of the things
10:11
- we learned at Centene
10:13
- about adherence in general, not just to GLP
10:15
- one medications,
10:16
- honestly, is that there really just isn't one
10:19
- issue that,
10:21
- prevents members from being adherent to their medications.
10:23
- It's really a combination of clinical factors,
10:27
- some practical factors, and really behavioral factors. And
10:30
- so when we think about specifically GLP ones,
10:34
- we see that some members really experience some
10:36
- tolerability
10:37
- challenges. So while these medications are highly effective,
10:41
- many members experience some gastrointestinal
10:44
- side effects or other tolerability issues that,
10:48
- we hear are keeping them from, you know,
10:50
- having long term,
10:52
- persistence on these medications, and and we see
10:55
- this in some of the data we track
10:56
- as well.
10:57
- There's also some practical barriers, and I think
11:00
- we saw a lot more of this,
11:02
- you know,
11:03
- earlier on when when these medications were were
11:06
- gaining favor for for obesity management. But members
11:10
- might encounter, you know, those supply chain issues.
11:12
- Right? Or, you know, jumping through, prior authorization
11:16
- requirements for the first time.
11:18
- Dose titrations are also common in some of
11:20
- these medications, and some of that could affect
11:22
- continuity.
11:23
- Certainly, some of those supply chain issues have
11:25
- largely resolved, but when I think about the
11:29
- potential
11:30
- utilization that this class might have over time
11:32
- and in places where the medications are being
11:35
- studied,
11:36
- I that utilization can grow. And so I
11:38
- think this is something we're monitoring to see
11:40
- if we can keep up with that demand,
11:42
- as it grows.
11:44
- And then I I think I mentioned behavioral
11:46
- factors. So, certainly, long term weight management,
11:50
- and chronic disease management
11:52
- require sustained lifestyle
11:54
- changes, and so medications alone are not usually
11:58
- the complete answer here. And so, really, you
12:00
- know, members maintaining that motivation,
12:03
- wanting to, you know, continue those healthy behavior
12:05
- changes also are factors that we kind of
12:08
- hear from our membership
12:10
- around the utilization of these medications.
12:13
- And then cost. You mentioned cost to, you
12:16
- know, the payer before, but also cost and
12:19
- affordability
12:21
- to our our members can influence persistence, you
12:24
- know, depending on the member's benefit design across
12:27
- those different lines of business we talked about,
12:29
- and their unique circumstances
12:32
- as well.
12:33
- So
12:34
- I state all that as, you know, some
12:36
- of the challenges, but what what are we
12:38
- at Centene doing really to
12:40
- address those challenges in a supportive way to
12:42
- our to our members and providers? Well,
12:45
- certainly, we're focused on,
12:47
- quite a bit of variety
12:49
- of interventions. And so we have pharmacy clinical
12:51
- outreach programs in which we talk to our
12:54
- members to support them,
12:56
- whether it'd be about education of their disease
12:59
- state, education about the medication, education on how
13:02
- to overcome some of those tolerability issues they
13:05
- might have in the beginning,
13:07
- encouraging adherence or, you know, tips
13:10
- around adherence,
13:12
- how, you know, do you sign up for
13:15
- auto refills at the pharmacy?
13:17
- Do you set reminders on your phone? Really
13:19
- very specific to an individual patient,
13:22
- and the barriers that they are addressing.
13:26
- We've also piloted and have connected some of
13:29
- this work with health coaches that we have
13:31
- in some of our health plans, and so
13:32
- we're really excited to see about how at
13:34
- work will pan out. And this is really
13:36
- us supporting
13:38
- an integrated approach to coordination of care, with
13:41
- both our
13:42
- care coordinators, health coaches, and pharmacists.
13:45
- And in this these cases, really, the goal
13:48
- is to help members, you know, navigate their
13:50
- therapy, manage the expectations they can have, and
13:53
- have have a team, you know, support team
13:55
- to go to when they have questions.
13:58
- Think another thing that we're doing that's important
13:59
- to call out is really the monitoring we're
14:01
- doing around the medications utilization itself, whether it's
14:05
- refill patterns,
14:07
- tracking new starts,
14:09
- looking for those adherence indicators, gaps in therapy.
14:12
- And that not only helps us identify which
14:15
- members to intervene in with those programs I
14:17
- just talked about, but I think it also
14:19
- helps us have a better understanding at a
14:21
- population level how these medications are being used
14:24
- or where we're seeing some challenges.
14:26
- It also helps us have some very pointed
14:28
- conversations with our prescriber community should they be
14:31
- able to to support,
14:33
- members on that end.
14:35
- And then, you know, finally, I just probably
14:37
- would wanna call out that
14:39
- certainly as a priority of ours to continue
14:41
- to make health care affordable,
14:44
- while supporting access to these innovative treatments. So
14:47
- I think one of the places that, you
14:48
- know, I'm really proud that we step into
14:50
- here at Centene is
14:52
- our collaboration
14:54
- in a lot of different spaces, but also
14:56
- particularly here with GLP ones with organizations such
14:59
- as ISER and other respected industry groups that
15:03
- that really help us,
15:05
- be a thought leader
15:06
- as emerging evidence comes out,
15:09
- as we continue to evaluate different ways to
15:11
- look at value based approaches, and
15:13
- that allows us to help inform policy as
15:15
- well to ensure that these therapies are available
15:18
- to patients who need them while maintaining that
15:21
- sustainability
15:21
- for a broader health care system.
15:25
- Certainly. So so clearly, Centene is doing a
15:27
- lot to to help members navigate some of
15:31
- these challenges and and clearly, it it takes
15:33
- a comprehensive
15:34
- program,
15:35
- to to have a modern program like this,
15:38
- Angel. And I also really appreciate the call
15:40
- out that this there's not any one issue
15:42
- in terms of what causes adherence,
15:45
- challenges that it's it's multifactor
15:47
- behavioral, clinical, financial,
15:50
- tolerability to these medications.
15:52
- You mentioned earlier,
15:54
- that the company has a multidisciplinary
15:57
- group,
15:58
- because you anticipated
16:01
- more indications,
16:03
- coming for these medications beyond,
16:06
- type two diabetes and and obesity treatment.
16:09
- And so as that landscape evolves,
16:13
- can you expand for us a little bit
16:14
- on how Centene is is keeping its formulary
16:17
- and clinical criteria
16:19
- up to date with, with what is such
16:22
- a rapidly expanding evidence base today?
16:25
- Absolutely. And I would say that the work
16:26
- group was really instrumental
16:28
- and and meets very frequently still. I think
16:31
- when we first started it, you know, we
16:34
- thought it might
16:35
- be short lived on a weekly basis, and
16:37
- then we could move to a to a
16:38
- more,
16:39
- a longer cadence. And and we found that,
16:41
- you know, we really just need to be
16:43
- monitoring this really closely,
16:45
- through that work group. But it's also important
16:47
- to have a really strong governance structure,
16:50
- and we certainly
16:52
- develop those clinical policies
16:54
- and stay up to date with the expanding
16:56
- evidence
16:57
- primarily through our formal PNT process, which stands
17:01
- for pharmacy and and therapeutics. And that's where,
17:04
- really, the rubber meets the road as it
17:06
- relates to evaluating
17:08
- the clinical evidence that's available and the and
17:11
- the, strength of that evidence, you know, the
17:13
- FDA approvals that are out there, the safety
17:15
- data, really some real world considerations. And so,
17:19
- you know, that clinical team, which is led
17:21
- by pharmacy,
17:22
- and other clinical leaders throughout our organization, is
17:25
- continuously monitoring that literature and and the evidence
17:28
- base. And what we're really seeing is the
17:30
- expansion beyond kind of the diabetes and weight
17:33
- loss really into broader cardiometabolic,
17:36
- renal, hepatic, and sleep related therapy areas. And,
17:40
- really, as those new indications receive regulatory approval,
17:44
- we have to consistently evaluate how those approvals
17:47
- align with our current clinical practice guidelines and
17:50
- the needs of our member populations.
17:52
- And then
17:53
- through,
17:54
- PNT and and those clinical
17:57
- individuals that sit on the PNT committee,
17:59
- we incorporate all of those findings into those
18:02
- formulary views and update our coverage as appropriate.
18:06
- At the same time, we're really closely monitoring
18:08
- the development of long term outcomes data, and
18:11
- so,
18:11
- you know, there's a lot out there where
18:13
- early clinical results are really encouraging,
18:16
- in many emerging indications,
18:19
- but the evidence
18:21
- for really sustained population health impact, health care
18:23
- utilization,
18:25
- etcetera, is is still evolving, and I think
18:27
- we're really excited to see to see that
18:29
- and incorporate that into future coverage policies and
18:32
- decisions.
18:33
- What I really hope you're hearing, Jacob, is
18:35
- that it's really important that we maintain,
18:38
- you know, a level of agility here, particularly
18:41
- in this GOP one space. So the landscape's
18:44
- moving very quickly.
18:45
- We use our formal governance process as well
18:48
- as, you know, more informal work groups to
18:50
- ensure we're staying up to speed with all
18:52
- the information that's out there.
18:54
- This includes us, you know, planning for different
18:56
- scenarios as drugs might hit the market. And,
18:59
- you know, right now, I think there's a
19:01
- lot in this space also being actively studied
19:03
- in Alzheimer's disease and substance abuse disorder.
19:06
- And those are places that I would say
19:08
- are currently on our radar to really, really
19:10
- watch, as this would bring in a whole
19:12
- new population of of patients that would be
19:14
- utilizing these medications.
19:17
- Certainly. And that is really what I'm I'm
19:18
- taking from from hearing you talk about all
19:21
- of this, Angel, is it's an extremely exciting
19:23
- time, from a clinical perspective
19:26
- around these medications, but
19:28
- being agile in this space,
19:30
- is is clearly critical, for success for for
19:33
- your members.
19:34
- And so in that vein, based off of
19:36
- everything we've talked about in in the last
19:38
- twenty minutes between your coverage policies, utilization management,
19:41
- adherence strategies,
19:44
- planning for additional indications.
19:47
- What are your what are your final thoughts
19:49
- that you would share with us or any
19:51
- final bits of advice that you would offer
19:53
- your pharmacy colleagues around the country who are
19:55
- navigating similar challenges?
19:58
- I I think I would align back to
20:00
- that being able to be agile
20:02
- and just,
20:04
- you know, not
20:05
- feeling comfortable in setting up things like maybe
20:08
- more informal work groups to get different perspectives,
20:12
- but making sure you have core core foundational,
20:15
- framework around your p and t committees to
20:18
- rapidly evolve your clinical policies in line with
20:21
- the evidence that's out there.
20:23
- I I think that
20:25
- we're all waiting for some of that longer
20:27
- term
20:28
- data to help push us in, you know,
20:31
- different directions around the utilization of these medications
20:34
- in different areas. And so I would say
20:36
- continue to monitor, continue to be diligent,
20:39
- and,
20:40
- you know, participate in the process.
20:43
- Wonderful. Well, Angel, I can't thank you enough
20:45
- for taking the time to sit down with
20:47
- us, chat about these important and and complicated
20:50
- issues, and and breaking it down in an
20:52
- easy to understand format for our audience. So
20:55
- so thank you very much for taking the
20:56
- time to do so. Thank you. Thank you
20:58
- for having me. And to our audience, if
21:01
- you'd like to listen to more podcasts from
21:03
- Becker's Healthcare, you can visit beckershospitalreview.com.