West Virginia Press Association Staff Report
CHARLESTON, W.Va. – The Joint Standing Committee on Insurance and PEIA, during the second day of December’s Interim Legislative Session on Monday, heard updates regarding PEIA’s (Public Insurance Insurance Agency) drug-rate study, as well as the agency’s financial plan. The updates were provided by PEIA Director Brian Cunningham.
“We’re pursuing a number of opportunities, both on the medical side and the pharmacy side to arrest costs and drive accountability,” Cunningham began, noting that PEIA is exploring a relationship with Quantified Health, an organization which performs forensic analysis of high-cost claims.
According to Cunningham, PEIA has thus far shared three such high-cost claims with Quantified Health. Each claim was over the $500,000 threshold, and originated from out-of-state providers.
“It’s a shared-savings model,” Cunningham said. “If Quantified Health identifies issues with billing, coding, appropriateness of setting, so on and so forth, and they recover money for PEIA, they share in some of that savings.”
Cunningham advised that PEIA is now working with 4C Digital Health, a TPA (Third Party Administrator) insight and review organization.
“As many of you probably know, PEIA conducts market analysis, we do an audit annually on our TPA, and this is just the next step of ensuring that TPA is held accountable,” Cunningham explained. “We’re in the pre-contract phase of that initiative right now, and again we’re seeking a shared-savings model. The initial approach is to look forward, not backwards.”
Cunningham further explained that PEIA is exploring prescription drug opportunities as well, such as True Data RX, noting, “That data exchange (with True Data RX) is underway.”
“We are seeking some initial opportunities around diabetes, weight management, and migraine medications,” Cunningham continued. “We’re taking an incremental approach to comparative-effectiveness, to minimize provider and member disruption. The previous pilot-project we had with True Data RX had some encouraging results, so we look forward to moving forward with them.”
Cunningham then briefly addressed current contract details of the Pharmacy Benefit Manager (PBM) for PEIA enrollees, saying, “We have an administrative-fee model.”
“”There is no spread pricing,” Cunningham added. “What I mean by spread pricing is that pharmacies are paid what the plan pays to the PBM. All rebates are required to be passed to the plan. The plan has the final say on the formulary, and there is no requirement for mail order, despite savings opportunity. That applies to both specialty pharmacy products, as well as all other pharmacy products.”
At the conclusion of Cunninham’s presentation, Del. Amy Summers, R-Taylor, asked Cunninham, “Can you describe to the committee what PEIA’s definition is of specialty drugs?”
AFter Cunningham stated his inability to accurately answer the question, Summers stated that, “It seems like in the past, specialty drugs were just something where you could make a lot of money. That was the definition. It didn’t take any specialized handling.”
In response to Summers’ next question, Cunningham advised committee members that, to the best of his knowledge, the PBM is not partnered with any specialty pharmacies operating locations within the State of West Virginia.
“My last question is from constituents of mine, and they asked me to ask you,” Summers said. “With PEIA, are you employed by the state, did you get the five percent raise, and will you pay the same premium increase that we’re asking of all the members?”
“That’s a great question, I’m glad you asked it,” Cunningham replied. “I am a state employee. I have PEIA. I have Plan C as a matter of fact – the high-deductible health plan with an HSA (Health Savings Account). I encourage others to look into that plan option.”
“I did not receive the five percent raise because I wasn’t here at the time,” Cunningham added. “But I will pay the same premium increase as everyone else pays, as will the other 55 folks who work at PEIA.”
Sen. Robert Plymale, D-Wayne, then requested some additional clarification regarding PEIA’s audit process, saying, “It was about 10 years ago or so that you went through making sure every person that was in PEIA their marriage certificates and things like that.”
“Is that still yearly now that you go back if you have somebody in question, you ask those questions?” Plymale asked. “It was pretty extensive 10 or 12 years ago.”
In response, Cunningham said, “We do require the appropriate documentation for folks to sign up for PEAI – to add dependents or remove dependents, so on and so forth.”
“One example of that is a marriage certificate, or birth certificate,” Cunningham added. “I know we’ve had more and more of the VISA documents that we now require to be provided. What I was referring to specifically with those audits is when there is a divorce, for example. By law, the policy holder is required to notify us when a divorce takes place, and the spouse should be removed from PEIA.
The West Virginia Legislature’s 60-day Regular Session is scheduled to begin on Wednesday, Jan. 10, 2024.
