It has become well-recognized that the most significant challenge in regard to the drug category of health care spending is controlling the use and cost of specialty drugs, which are typically biologics that are not orally administered. EMD Serono puts out an excellent report on these drugs, with the 2012 version just being released. (EMD Specialty Report) The introduction focuses on adherence, which may be a particular issue with specialty drugs since they are expensive and patients often bear a good portion of that cost. Information in the report, based on IMS research, suggests that for every 100 prescriptions, only 50 to 70 are filled, only 48 to 66 are picked up, only 25 to 30 are taken as ordered by the doctor and only 15 to 20 are refilled. While these numbers may be exaggerated since physicians may order medications that patients don’t really want or need; they do give some sense of the scope of the adherence problem. Increasing adherence would obviously benefit the drug manufacturers and pharmacies, but may also help patients and may reduce other categories of health cost.
The survey portion of the report comes from 102 health plans covering over 122 million people. Health plans are focused on identifying specialty drugs, with most using as criteria high cost, the need for special handling of the drug, the drug treats a rare disease and it has a limited distribution. Once a drug is put in the specialty category, there are a number of consequences, including more patient cost-sharing, a potentially limited pharmacy source and more utilization management measures. Among common specialty drug categories are oncology, arthritis, asthma and multiple sclerosis. The most common specialty pharmacy management strategies are use of prior authorization under the pharmacy benefit, used by about 90% of health plans, use prior authorization for medical benefit drugs, used by about 80%, limit supply to 30 days, used by about 75% and select preferred products used by about 73%. For some reason that is hard to understand, Medicaid plans tend to use slightly less of all these techniques. More tomorrow.