Specialty Drug Digest, Last Part

At long last, I am done going on and on about specialty drugs, as this is the last part of the review of the EMD Serono Specialty Drug Digest.  Today we talk about networks, specific categories and the future.  About half of plans have more than one specialty pharmacy in their network.  The primary reason for this is that certain compounds may have exclusivities or may require special handling, and in some cases state regulations may require a more open network.  Specialty pharmacies tend to do dispensing of medications, coordinate patient eligibility and reimbursement and promote adherence, provide reporting, and help with utilization management, including prior authorization.  Satisfaction is highest for dispensing and patient services and lowest for medical management and reporting.  Most plans mandate that at least some drugs must be received from a specialty pharmacy.  Multiple sclerosis, rheumatoid arthritis, hepatitis C and several other categories commonly fall under such a mandate.  Health plans use a number of other vendors to provide certain services, although at relatively low rates, including claims repricing, code crosswalks, forecasting and modeling, and site of service management.

Looking at a couple of particularly challenging therapeutic categories, oncology of course is the single largest category and is identified by most plans as one of their top challenges in the specialty drug arena.  In terms of specific actions and the gap between how plans rate their importance and their actual performance, reducing drug costs has the biggest gap, followed by reducing ER and hospital use and getting complete data on costs and outcomes.  Primary goals for 2018 were listed as reducing drug costs, using evidence-based guidelines and getting more data.  Only 42% of plans said they used oncology clinical pathways, which is astoundingly low, with over 80% of the plans that do saying they collaborate with oncologists to develop the pathways.  48% make the use of pathways mandatory and 20% use incentives to encourage pathway compliance.  Plans estimate that 65% of oncologists comply with a pathway.  Many plans are requiring use of available companion diagnostics before approving use of a drug.  Next up is multiple sclerosis.  Here primary goals were reducing drug costs, improving rates of remission and getting better data.  Medication adherence has been a significant issue for this disease, with only 61% of patients meeting adherence goals.  Tactics plans are using to control MS costs include prior authorization by 61%, step therapy, use of a specialty pharmacy and day supply limits, each with over 60%.  Only 20% of plans use clinical pathways for MS and 42% of those make the pathway mandatory.

Looking forward, plans are beginning to have specific policies regarding the emerging biosimilars, with 56% requiring prior authorization for use of a branded product when a biosimilar is available.  Legislative restrictions (which are unbelievably stupid when Congress says it is concerned about drug costs) limit the ability to mandate use of biosimilars but plans can use financial incentives to encourage their adoption by patients.  The expected savings, however, are much smaller than I would have thought, at only an average of 9%.  In terms of overall future trends, coordination across benefits is still the biggest area mentioned for action in 2018, followed by enhanced claims-reporting, renegotiating infusion rates, using outcome or value-based reimbursement or bundled payments.  In terms of benefit design actions, providers will be thrilled to know that the number one item is more use of prior authorization and use of cost-sharing levels to incentivize use of certain sites of care or certain products.  The report is useful not just for what it tells us about specialty pharmacy, but because many of the tactics apply to other high-cost therapies.