Specialty drugs are critical focus for payers

June 1, 2013

The appropriate use of specialty drugs is a major priority for health plans and will become increasingly important for future growth over the next 3 to 5 years, according to a comprehensive survey on payer approaches to specialty drugs. Furthermore, the research finds significant variation in what health plans view as emerging areas of opportunity to manage these drugs.

The appropriate use of specialty drugs is a major priority for health plans and will become increasingly important for future growth over the next 3 to 5 years, according to a comprehensive survey on payer approaches to specialty drugs. Furthermore, the research finds significant variation in what health plans view as emerging areas of opportunity to manage these drugs.

“Specialty drug management is a critical focus for payers,” Leigh Ann Bruhn, director at Avalere Health, who conducted the study, told Formulary. “Payers are experimenting with a wide range of approaches, all the way from innovative approaches to payment and care delivery to how they construct their benefits. Over time, these investments may produce results that can provide guidance on meaningful ways to ensure appropriate access.”

The study, titled DIMENSIONS of Specialty Pharmaceuticals: Evolving Trends in Market Access, presented findings that included the following:

Ÿ National plans have shown themselves to be early integrators of specialty pharmaceutical management into ongoing plan processes.

Ÿ Payers are investing in changes to systems of delivery of specialty pharmaceuticals; such changes are “established” in 45% of national plans and emerging in regional plans at a rate of 93% and in integrated systems at a rate of 94%.

Ÿ There is also variation in changes to payment systems: 60% of IDSs have already established key changes and 92% of national plans are considering them.

Ÿ All types of health plans say provider acceptance is the most important single factor in ensuring success.

Ÿ Collaboration is another factor viewed by many as essential to a successful program.

Ÿ National plans and IDSs engage with accountable care organizations more often than regional plans do.

Ÿ Investment in IT infrastructure was a priority for 95% of national plans and 93% of IDSs; only 30% of regional plans were engaged in such IT development.

“As utilization and costs for specialty pharmaceuticals continue to grow as a significant portion of healthcare spend, each and every stakeholder in the healthcare market is looking for innovative solutions to drive appropriate use while managing costs,” said John Unger, group product director, payer marketing at Janssen Biotech, which commissioned the study.

He continued, “Specialty pharmaceuticals is a dynamic and complex marketplace. It is also well known that specialty pharmaceuticals provide tremendous value to patients who suffer from chronic, debilitating diseases. Due to a number of complex issues related to their cost, special handling, site of delivery, and side-effect profile, they have spawned a rapidly emerging market. We anticipate a growing number of new players in the healthcare marketplace, if not perhaps even manufacturers themselves will provide solutions to these complex issues: new delivery models, sites of care, adherence programs, integrated benefit designs and healthcare information technologies.”

Effective management requires new tools and programs, such as site-of-care optimization, that have not been used in traditional pharmacy management, said Unger. “Due to the nature of specialty pharmaceuticals, close collaboration with physicians, specialty pharmacies, and emerging third-party organizations are critical to the successful implementation of these programs. It is critical to think beyond unit cost management and traditional pharmacy claims tools.” Areas of opportunity identified in the report include payer/provider contracts for centers of excellence, reauthorization to continue drug therapy, and shared-savings payment programs.

“This research shines a spotlight on the vast amount of experimentation taking place in the market to achieve these goals,” said Unger. “Not only do we explore what payers are doing, but we dive deep into the drivers, barriers, and critical success factors.”

He added, “What we learned through the survey is that plans pursue different activities based on what they believe will have the higher likelihood of success. So, for example, the most common activities conducted for site-of-care optimization were noted as case management and prior authorizations. The drivers are that delivery and payment system changes are expected to have more growth and impact on specialty drug utilization and patient outcomes than other drivers like innovative contracting agreements and medication adherence. The lack of internal organizational support, available resources, and limitations in IT are cited as barriers to successful implementation of most of the emerging solutions. Provider acceptance was cited as a critical success factor for 60% of the activities for each health plan type.”

The survey, conducted by Avalere Health and commissioned by Janssen Biotech and Johnson & Johnson Health Care Systems, was conducted in November and December 2012 with 90 respondents, including representatives of national and regional health plans, integrated delivery systems, pharmacy benefit managers, self-insured employers, and employer coalitions. Before the survey was issued, areas of ignorance of specialty pharmaceuticals were delineated and 8 areas of interest were targeted for development in the survey. An editorial board composed of members from across the industry reviewed the survey’s conclusions.