Today’s advances in medicine enable the successful management of diseases for which there were once few effective treatment options.
However, innovative specialty medications come at a cost upward of thousands of dollars per dose.
In fact, specialty drugs are so expensive that they drive 40% of today’s prescription spending while treating less than 1% of the patient population. National strategies for managing the cost of these drugs include promoting biosimilar development and increased competition, but there are steps plan sponsors can take now with pharmacy benefit managers (PBMs) to address spending on specialty drugs.
Improved care coordination and communication
Controlling specialty spend is about supporting patients and working with their healthcare team to ensure that treatment is safe and effective. Medications that don’t work as they should translate to poor health outcomes, which drive up overall costs.
PBMs are perfectly positioned to work with all members of a patient’s healthcare team to improve communication. PBM pharmacists have access to all data gathered from prescription claims and, potentially, integrated medical claims data. This allows them to see a comprehensive picture of the patient’s medication history, diagnoses, lab results, indicators of adherence and other applicable medical data. As a result, PBM pharmacists can alert prescribers and retail pharmacists of any issues and facilitate the identification of safer, more effective treatment options.
Specialty pharmacists and nurses should speak directly with their patients as well about the medications they’re taking and how they’re feeling. This dialogue develops a rapport, trust, empathy and understanding. It also allows these clinicians to work with the patient’s healthcare team to address any challenges that may arise—such as poor medication adherence due to intolerable side effects or complicated dosing schedules.
Through this outreach, the PBM becomes a patient advocate, bringing all members of a patient’s healthcare team together to find treatments that deliver the best value and outcomes.
Advanced clinical programs
To be able to provide effective care coordination, PBMs must also offer comprehensive, advanced clinical programs. Prior authorization provides an example of how clinical programs are not created equal. The intention of prior authorization is to make certain medications are used appropriately. But does the analysis review whether the medication is appropriate for a specific individual’s needs? Not all prior authorization programs do. A comprehensive program considers whether there are warnings and contraindications related to factors such as the patient’s age, health conditions, metabolism, lifestyle or other medications they may be taking.
Advanced clinical programs are proactive, delivering vital information before a medication is dispensed so adjustments can be made without putting patients at unnecessary risk. This can reduce spending by preventing serious adverse drug reactions or wasteful drug utilization.
In addition, quantity limits can be used to eliminate excessive spending by cross-referencing the amount of medication being dispensed with the actual amount of medication being billed. For example, if the quantity in a prefilled syringe is rounded up for billing, the plan sponsor is overcharged. For specialty medications costing thousands of dollars, the financial impact is significant.
Creative contracting and partnerships
Finally, plan sponsors need a PBM that works with them, putting the plan’s and patients’ best interests first while delivering ethical, transparent benefit management. They should consider PBMs that tie performance guarantees directly to their clinical programs. A pay-for-performance arrangement holds the PBM accountable for how well it facilitates responsible, effective drug utilization that reduces the plan’s spending.
In addition, plan sponsors can seek out direct savings by partnering with a PBM that provides actual acquisition cost pricing on specialty medications. This means that the plan sponsor pays exactly what the pharmacy pays for the medication, without any markup or spread generating hidden revenue.
Specialty medications are an increasingly important part of the drug spending equation. Rather than wait for external factors to drive savings, such as competition and biosimilar development, plan sponsors should challenge the status quo, ensuring their PBM partners are transparent and proactive. Specialty spending can be controlled by making strategic choices in PBM relationships that support better patient care and drive transparent, accountable programs and results.
Michael A. Perry is the president of BeneCard PBF, an innovative PBM that engineered a purely transparent pharmacy benefit management model along with a pure pass-through program. BeneCard PBF’s approach centers on clinical programs that drive costs down while helping improve member health outcomes.