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Cost Savings in the Specialty Medical Benefit
San Diego—In 2014, only 1% of US prescriptions were specialty drugs, but they represented 31.8% of drug spend. This was a 27.7% increase from 2013, and specialty drug utilization in both the medical benefit and pharmacy benefit markets is expected to significantly increase over the next year.
During a session at AMCP, Jody H. Allen, BS, PharmD, FASPH, vice president, clinical account management, Express Scripts, and Mary Dorholt, PharmD, vice president and clinical practice lead, Specialty Express Scripts, spoke about the cost challenges of specialty drugs and tools that can be utilized to decrease medical benefit cost.
According to the Express Scripts 2014 Drug Trend Report, in 2014 the US prescription drug spend increased 6.4% for traditional drugs and 30.9% for specialty drugs, leading to an overall increase of 13.1%. “We have not seen an [increased] rate of drug spend at 13% in over 10 years,” said Dr. Allen. “Specialty spend is almost 50% of the spend next year.” Primary condi- tions that are expected to drive the trend toward specialty drugs include inflammatory conditions, hepatitis C, and oncology. Dr. Allen reviewed multiple factors that are triggering the continuous increase in specialty drug spend. Increasing utilization, therapy administration, and pharmaceutical manufacturer pricing and marketing are increasing the specialty trend as well as the expansion of specialty treatment areas such as idiopathic pulmonary fibrosis and immunotherapy for oncology. Another specialty drug trend driver is the increasing prevalence of orphan drugs. “Seventy-five percent of drugs approved last year had an orphan drug status,” said Dr. Allen. “All of these [factors] will continue the explosion we are seeing in the specialty drug market.”
The field of oncology is greatly influenced by the specialty drug trend. As new treatments emerge, survivorship among oncology patients increases. Dr. Allen pointed out, as certain cancers characterization transitions from terminal illness to chronic illness, there is an “increased need for managing these costs.” The growing complexity of treatments, expanding number of cancer diagnoses, and rising use of orals has generated a demand for advanced care and decision support as well.
From 2012 to 2014, Express Scripts conducted an internal analysis of 851 clients to determine the difference in cost between unmanaged plans and tightly managed plans. Tightly managed plans experienced a 6.4% decrease in specialty drug costs from 20.2% to 13.8% compared to unmanaged plans. According to the analysis, an unmanaged plan sponsor would have saved $11.25 in specialty spend per member per year if they had managed their plan. Dr. Allen said “[tightly managed plans] did not decrease in quality of care, but [created an] increased adherence [rate].”
The session continued with Dr. Dorholt explaining the importance taking specialty medical management into account, not just specialty pharmacy. “[The] specialty trend continues to increase,” said Dr. Dorholt. Very robust specialty medications will continue to hit the market.
Medical specialty drug spend is furthered by 4 factors: (1) expensive sites of care; (2) inaccurate billing; (3) inappropriate utilization; and (4) increased complexity of care. Dr. Dorholt provided statistics regarding these trends. According to the 2011 Express Scripts Trend Report data, expensive sites of care increased in use by 14%. Also, >15% of medical drug claims were inaccurately billed. In 2011, inappropriate utilization by plan sponsors wasted $13 billion each year. About 35% of oncology treatments plans deviated from evidence-based guidelines in 2013, and as Dr. Dorholt pointed out, “Treating patients with unapproved guidelines limits the effectiveness.” These issues open up opportunities to improve care and spending, said Dr. Dorholt.
In order to adapt to the increase in specialty drug utilization, a comprehensive management approach is necessary, said Dr. Dorholt. She cited a tool created to prevent unnecessary medical spending in oncology. The Medical Benefit Management developed by Express Scripts utilizes 5 features to achieve an integrated prior authorization and the claims systems: (1) utilization management; (2) site of care management; (3) claims prepayment review; (4) patient safety and waste; and (5) oncology decision and support. The goal is to create an automated system so physicians integrate the approach into their daily workflow.
Dr. Dorholt reviewed the 3 principals to improving utilization management: (1) prior authorization; (2) step therapy; and (3) drug quantity (Table).
Another area that will reduce specialty medical and pharmacy spend are biosimilars. Once a drug patent expires, a biosimilar will most likely be in the pipeline. This could lead to $250 billion in savings through 2024.
Moving patients from hospital outpatient-based care to medical office care would reduce unit drug costs and administrative costs. Total costs would decrease even further if the patients could receive home-based care.
Claims prepayment reviews could verify if claims are accurately made and paid. Implementing an automated system would assist in identifying discrepancies. “[Plans] could have bills coming through for drugs [that were] never prescribed,” said Dr. Dorholt. “Also the ability to manage vial size and dosing size [is crucial to improving utilization management].”
Dr. Dorholt ended the session by actualizing the advantage to the Express Script’s Medical Benefit Management system. Express Scripts projects a 20% increase in specialty drug trend over the next few years; plan sponsors can save approximately $9 billion this year if they control specialty costs in the medical benefit.—Melissa D. Cooper
