Pharmacy spending soars in Tucson area under Cenpatico
Three local behavioral-health agency leaders say the limited pharmacy data they have from Cenpatico indicate average monthly pharmacy spending on their patients soared by 53 to 83 percent this year.
"I've never seen anything like that level of increase in that short a period of time," said
Cenpatico and AHCCCS, the state's
Pharmacy spending for the three behavioral-health providers -- COPE,
The three providers are
The comparison between Cenpatico and CPSA expenditures has weaknesses: The providers requested pharmacy data from Cenpatico but got back only selected monthly spending data for different time frames -- three, two or one month. For example, CODAC's increase of 53 percent was based on just one month of spending data from Cenpatico.
Before Cenpatico took over the region's public behavioral-health system last year,
FACTORS IN SPENDING
Pharmacy spending factors include doctors' prescribing habits, drug innovations that result in better but more costly medications, drug company pricing, medical inflation and fees paid to a third-party pharmacy benefit management company.
The impact of fees paid to the pharmacy benefit manager is unclear: The Star obtained a copy of Cenpatico's contract with its sister company
Cenpatico is one of three regional behavioral-health authorities that contracts with the state's
Cenpatico, a subsidiary of the publicly traded insurance giant
Sen.
"The more transparent you can be, the better," said Bradley, who has worked in behavioral health for 35 years. "Maybe it's simply the increased cost of medications, but if you leave this cloaked, it's hard for people to come to the same conclusions you're coming to."
DRUG REBATES
AHCCCS Deputy Director
Drug companies give rebates to government agencies like AHCCCS in the hopes of getting their medications on the agency's preferred drug list. That's resulted in more brand-name drugs on AHCCCS' preferred drug list, but the rebate funds should more than offset any spending increases, Kohler said. Savings from the rebates go directly to AHCCCS, so they aren't reflected in Cenpatico's bottom line.
Kohler said she'll know more once AHCCCS fully analyzes its contracted companies' financial records later this year to determine whether it should adjust what it pays contracted managed care organizations, she said.
A recent review of overall -- not just pharmacy -- spending trends among regional behavioral-health authorities shows that Cenpatico, covering
"Based on our review, it's still well in line with, and in fact probably better than, the national averages," he said. "I don't think we have enough data at our level to fully explain the increase."
The spending increase does not appear to be due to more prescribing by doctors. The number of prescriptions went down over the past year for patients, the three providers said. But compared with CPSA, per-prescription spending has increased by an average of 145 percent under Cenpatico, according to the months of data available.
In addition to psychiatric prescriptions, Cenpatico's pharmacy expense data included drugs to treat medical conditions for enrollees with serious mental illness, who now get their medical and behavioral-health care covered by Cenpatico. The providers excluded medical prescriptions to make a fair comparison CPSA spending, which did not include medical care for enrollees.
SISTER COMPANY
A third-party pharmacy benefit manager oversees prescription benefits for a group of insured people. It typically negotiates with drug companies, manages drug formularies and prior authorizations, and compiles data reports for contracted insurers like Cenpatico or large employers.
Cenpatico contracts with pharmacy benefit manager
Under its contract with AHCCCS, Cenpatico's potential profits, and losses, are limited to 4 percent of the amount AHCCCS pays the for-profit company each year, projected to be
During the first three quarters of Cenpatico's first contract year here -- the period between
Kohler said Cenpatico is incentivized to make sure its contract with its pharmacy benefit manager is cost-effective.
"Even if they are a sister company, spending more obviously impacts their own finances," she said.
ACCESS ISSUES
Burgeoning pharmacy spending is on Cenpatico's radar. A Cenpatico PowerPoint presentation obtained by the Star shows that, between January and September of this year, its pharmacy spending exceeded its
The initial budget didn't take into account more costly drugs that may have been added to the preferred drug list due to the drug-company rebate program, said
"We do not have any concerns about our pharmacy program," she said in an email. "Obviously, ensuring access to needed medications is a critical part of helping our members manage their own health and avoid costlier settings for their care, like the emergency room."
But some patients say they've encountered more problems accessing their medications under Cenpatico compared with CPSA.
For AHCCCS patients classified as having serious mental illness, Cenpatico now provides both medical and behavioral-health insurance under a new "integrated care model."
Mueller, who also has depression and anxiety, said he never got an explanation as to why Cenpatico wouldn't cover the Advair inhaler, even though it was listed on their formulary.
"I went to the pharmacy one day and they said the insurance won't fill it," he said. When he called Cenpatico, he was told the doctor's office hadn't faxed a prior-authorization form, but his doctor said the forms were sent repeatedly.
The inhaler would have cost Mueller
"I was coughing and wheezing for over two months while I tried to figure it out," he said.
Contact reporter
or 573-4233. On Twitter: @EmilyBregel
___
(c)2016 The Arizona Daily Star (Tucson, Ariz.)
Visit The Arizona Daily Star (Tucson, Ariz.) at www.tucson.com
Distributed by Tribune Content Agency, LLC.
Tackling your finances at Westlake Hall in Peoria
Advisor News
Annuity News
Health/Employee Benefits News
Life Insurance News