The 13th edition EMD Serono Specialty Digest outlines top specialty drug management issues health plans face.
Health plans are moving to a more mature specialty drug management stage, according to The 13th edition EMD Serono Specialty Digest, from EMD Serono, the biopharmaceutical business of Merck KGaA, Darmstadt, Germany.
Payers are moving beyond “value” and a single therapeutic area to the clinical management of specialty drugs as a whole, according to Matt Spiewakowski, director, payer marketing, market access and customer solutions, EMD Serono.
The 13th edition EMD Serono Specialty Digest outlines the results of a survey of 58 commercial health plans representing 173 million covered lives in 2016, and provides objective market data on health plans’ management of specialty pharmaceuticals and identifies common trends occurring across plans.
Results of the 13th edition survey determined that 83% of respondents ranked ‘ensuring clinical use’ among their top five challenges, with ‘managing oncology drugs’ and ‘determining the value of specialty drugs’ ranking second at 79%.
Here are the top 5 specialty drug management issues faced by health plan respondents and why these remain challenging, according to Spiewakowski.
1. Ensuring clinical appropriateness (24% of respondents ranking it as a top challenge, compared to 12% last year). “Typically, the diseases that require treatment with specialty medications are associated with smaller patient populations, but with very complex, very heterogeneous circumstances for each patient,” Spiewakowksi says. “Defining clinically appropriate use can vary very widely from patient to patient.”
2. Managing oncology drugs and service (21% of respondents compared to 28% last year).
There are many instances when there is no universally agreed pathway for treating patient with various types of cancers, according to Spiewakowski. “When treatment pathways are not standardized, management becomes labor-intensive and prone to inconsistency,” he says.
3. Determining value of specialty drugs (17% compared to 26% last year).
‘Value’ can be defined in any number of ways, Spiewakowski says. “Inconsistency among drugs, expected outcomes, health economic analyses, data infrastructures, and clearly defined disease management measures all lead to a lack of robust, reliable, and standardized outcomes data across the industry,” he says. “Outcomes data is critical to helping determine value.”
4. Responding to the drug pipeline (10% of respondents compared to 7% last year).
Although we live in a time where many new specialty drugs are being approved, these drugs must also be carefully evaluated to determine appropriate clinical utilization, according to Spiewakowski. “This takes significant time and effort, when in reality the specialty drug may be appropriate for only a very small population of patients,” he says. “This process must be balanced while managing utilization for drugs that impact much larger patient populations, like high cholesterol or diabetes.”
5. Coordinating across pharmacy and medical benefits (16% of respondents compared to 12% last year).
Pharmacy and medical benefit claims are typically separate functions/departments within a given healthcare organization, however many improvements in cross-functional coordination have been achieved in recent years, Spiewakowski says. “New ways to improve the effectiveness and efficicency of sharing information are always being explored,” he says.
In order to tackle these challenges, Spiewakowski suggests a strong investment in IT infrastructure and technology to help facilitate the flow of information. “Good decisions on specialty drug management are made by utilizing good data, including not only pharmacy data, but also medical data, laboratory data, and outcomes,” he says.
The EMD Serono Specialty Digest helps health plans, employers, specialty pharmacies and pharmaceutical companies to identify current and future trends in the management of specialty pharmaceuticals, and is often used to help inform strategic decision making.