Payers’ Views on Specialty Pharmaceuticals Market

San Diego—Between 2007 and 2011, specialty drug costs grew from 15% to 20% each year, whereas spending on traditional drugs increased <5% each year, according to the Express Scripts 2011 drug trend report. Specialty drug spending is expected to grow ≥20% in the next 2 years, as well.

Recognizing the rising costs of specialty drugs, a group of researchers designed a survey to assess how payers are dealing with the issue. They presented preliminary results during a Contemporary Issues session at the AMCP meeting titled Dimensions for Specialty Pharmacy: Evolving Trends in Market Access.

Janssen Biotech, Inc. funded the research and helped Avalere Health LLC design the survey and analyze the findings. Detailed results are expected to be released this summer on Avalere Health’s website.

Lauren Barnes, senior vice president at Avalere Health, said the report focused on payers’ perspectives on the current and future management of specialty pharmaceuticals. Helen Sherman, RPh, PharmD, vice president at Solid Benefit Guidance, LLC, also spoke about the results. Ms. Barnes and Dr. Sherman were members of the editorial board that provided analysis and perspective on the report.

Dr. Sherman said the data were “complicated,” but she added that they provided an opportunity to assess the industry and how payers think the specialty pharmaceutical market will evolve.

In all, 90 companies responded to the survey, including 64 national and regional health plans, 11 employer coalitions, 8 self-insured employers, and 7 pharmacy benefit managers. Of the health plans, 34 were regional carriers representing a total of 27,520,179 lives, 17 were integrated delivery systems representing 5,010,200 lives, and 13 were national carriers representing 87,230,000 lives.

Before designing the survey, the researchers identified areas of interest in specialty pharmaceuticals, including delivery system changes, payment system changes, site-of-care optimization, clinical pathways, medication adherence, innovative contracting arrangements, benefit design, utilization management, and medical and pharmacy integration. In each area, respondents were asked whether they had observed any activities in the category. They revealed they had invested in >800 individual activities related to the area.

The survey found that 77% of respondents said new payment methods were emerging, defined as witnessing multiple instances of the methods but not common practice. Further, 65% of respondents said new approaches in care delivery were emerging, while 62% said new approaches to benefit management were emerging.

On a scale of 1 (not likely) to 5 (very likely), national health plans and integrated delivery systems had an average response of 4.1 when asked if they were likely to achieve success in the areas compared with an average of 3.8 for regional health plans. However, the respondents said they had limited support within their organizations to make further changes, according to Dr. Sherman.

Of the potential opportunities, changing delivery and payment systems were viewed as having the best potential at improving specialty drug utilization and patient outcomes. National health plans responded that the opportunities were more mature than the other groups, while integrated delivery systems had already established medical and pharmacy integration and clinical pathways compared with regional or national health plans. Integrated delivery systems were also pursuing more activities related to site-of-care optimization, with the most common activities being care management and prior authorization.

Of the 64 plans, 11 had created an accountable care organization (ACO) demonstration project, 19 had an ACO-like structure, 22 were considering establishing an ACO, and 12 were not planning on starting an ACO.

Other activities that the respondents considered as promising included establishing centers for excellence partnerships between payers and providers and implementing episode-of-care payments.