1. Stretching State Health Dollars in Difficult Economic Times: Pharmaceutical Purchasing Strategies Tanya Alteras Economic & Social Research Institute Families USA, January 28, 2005 Washington, D.C.

2. "The chance of dramatic [national] reforms are next to zero.... Like it or not, we are stuck with what we have for the foreseeable future." -Rep. Tom Feeney, R-Florida, November 3, 2004 In the face of less-than-likely national reforms, states will continue to pursue state- and community-based solutions to the health care crisis.

3. State Responses to Skyrocketing Health Costs Two General Strategies: Address cost increases in Medicaid/SCHIP/state health programs by: Cutting eligibility, benefits, reimbursement to providers Raising premiums and other cost-sharing Stretch health dollars to expand health care access, coverage, and efficiency by: Leveraging private &/or federal dollars More effective purchasing, cost-effective primary and preventive care, better management of diseases

4. Why Rx Purchasing Strategies? States estimate an average of 14-15% annual increase in Medicaid Rx spending from 2001-2004 Need to make Medicaid and other state Rx purchasing more affordable Desire to expand Rx programs to vulnerable populations

5. Common Theme Across Various Effective Purchasing Strategies: States pooling together and using evidence-based research to guide their pharmaceutical purchasing in order to reduce costs and increase efficiency.

6. Typology of Identified Strategies Substitutions, Preferred Drug Lists (PDLs), and supplemental rebates State-negotiated discounts Multi-state purchasing & evidence-based research collaboration Intrastate purchasing Multi-state drug re-importation collaboratives

7. National Medicaid Pooling Initiative MI, VT, NH, NV, AK, MN, HI Common PBM pools purchasing power to negotiate, get supplemental rebates from drug companies tied to volume Give smaller states purchasing benefits of larger states Enhances savings from PDLs: MI savings: $60.5m from PDL, $7.2m from rebates (expected to increase as pool grows)

8. RXIS: Multistate Rx Purchasing Pool WV, MO, NM, DE, OH Common PBM negotiates rates for state workers, SCHIP (only in WV). States pays higher admin but capture entire rebates WV saved $7m year 1, expect $25m over 3 years

9. Drug Effectiveness Review Project Overseen by the Oregon Center for Evidence- Based Policy States pool resources to evaluate pharmaceuticals in 25 drug classes Set standards for comparing drug effectiveness (use for PDLs) Focusing on clinical outcomes 11 states participating as of July 2004

10. Maine & Hawaii Rx Plus State-negotiated discounts for residents to 350% FPL w/o drug coverage Estimated savings of 15% for brand Rx, 60% for generics on PDL In ME, program survived legal battles by pharmaceutical industry HI plan began on July 1, 2004

11. Georgia Consolidated Drug Management State contracts with one PBM for multiple state agencies and programs Rx benefits, covering almost 2 million residents One PDL established across all programs Rx cost growth trend line reduced from 26% in FY 2001 to 16% in FY 2002.

12. I-Save Rx IL, MI, WI, KS Multi-state program using reimported drugs from Canada, Ireland and UK States contract with CanaRx (PBM) Currently 1,200 enrollees

13. Next Steps and Issues to Consider Broadening programs to include additional states Deepening discounts and increasing rebates to make programs even more cost-effective Impact of Medicare Part D on state-based Rx programs Ensuring the use of evidence-based research in developing cost-savings strategies Challenges from pharmaceutical industry

14. Overall Lessons Learned Some strategies do not have high short term costs, but redirect current funding streams opposition… Building consensus and buy in among stakeholders is critical Some strategies require up-front investments ($ and time investment) But must factor in financial and health-outcomes related benefits over the long term Need to address budget shortfalls w/ creative financing models… Requires outside-the-box thinking Most of these state strategies help in an incremental way… Significant impact requires comprehensive, combination approach (or national commitment) *** States must be active players ***