In the final segment of the EMD Serono Specialty Digest, pharmaceuticals used for treating cancer are examined and the use of specialty pharmacies. This is probably the single largest category of specialty drugs and the pipeline of new products is over 900 strong. Several of these are approved by the FDA each year and they add significantly to overall health spending, as a course of treatment is often tens of thousands of dollars. A number of management strategies have been adopted by health plans to attempt to ensure appropriate use of these drugs, including limiting coverage to approved FDA indications, not the frequent off-label uses by oncologists and increasing oversight through clinical guidelines and pathways. The most popular set of guidelines are those from NCCN/ASCO. Plans are also promoting use of palliative care end-of-life programs, which avoid usually futile courses of treatment with expensive drugs. Over 50% of plans already use some form of guideline and of those, 90% are providing incentives to physicians for following the treatment pathway. Pathway availability tends to follow the most common cancers, but increasingly even rarer cancers are subject to some guideline for drug use. Along with specialty drugs now typically come companion diagnostics, usually based on genetics, which are themselves expensive but which can help ensure appropriate use of the drug. Some plans require prior approval for the test. Almost all require use of the companion diagnostic when one is available and that physicians use the result of the test to guide treatment. One trend which has increased cancer costs significantly is the shift in infusion from doctors’ offices to hospital outpatient departments, which often charge significantly more for the same services and drugs.
Finally, most plans use at least one specialty pharmacy provider or manager, hoping to draw on their expertise to save money and improve outcomes. About two-thirds of plans require use of a specific specialty pharmacy for self-administered agents. Among the areas that plans are counting on specialty pharmacies to handle well are dosing, adherence, waste and abuse and outcomes, but less than half of plans express satisfaction with performance in at least some of these areas. Probably due to this lack of satisfaction, plans are seeking more performance guarantees from their specialty providers. Plans want outcomes measured in terms of efficacy, quality of life, ability to work, lack of adverse events and cost, both of the drug and overall medical costs.