Preparing Payers for the New Therapies in the Pipeline

In an upcoming session at PBMI’s 2019 Specialty Rx Forum, Susan Trieu, PharmD, director of enterprise specialty clinical solutions at MedImpact Health Systems, will discuss new therapies in the pipeline and what payers should focus on. First Report Managed Care recently spoke with her to learn what attendees can expect and offer a preview of the upcoming session.

Please introduce yourself and tell us about your background. 

My name is Susan Trieu. I’m a PharmD, so clinical pharmacist by training. I was with a couple of big pharmaceutical companies prior to joining the managed care world.

The unique skill sets I learned from the pharmaceutical industry aid in my understanding of clinical trial development. In my current position at MedImpact, I am able work in the specialty area. Specialty is growing very quickly and although it only makes up 1% or 2% of total claims—specialty drug spend is almost 50% of total spend.

I work with payers but also am able to work with clinicians in specialty pharmacies that care for patients every day.

You’re presenting at PBMI Specialty Rx Summit in September. Can you give a brief overview of what that presentation will focus on?

That presentation, is entitled, “Are You Ready for the Next Generation Therapy?” During this presentation, I will alert the participants to new drugs in the pipeline.

New therapies that are in the pipeline that potentially will revolutionize treatment in the near future. It will range from orphan diseases to more common specialty disease states. 

The presentation will raise questions about whether plan sponsors are prepared to evaluate how new drugs and treatment modalities are working. How do they budget for them? Where do they budget for them? Is it on the pharmacy benefit or on the medical benefit?

How do you truly manage these types of innovations treatments? We’ve not had gene therapies that have hit mainstream America yet, but we will. What do we actually do with those particular agents? What are the appropriate patient populations?

How do you determine utilization management criteria, and how do you evaluate those types of treatments; it will be very different from what we’ve done traditionally in the past. That will be the focus of my session.  

We’ll go through top line things, and then we’ll get to the nitty gritty and how you evaluate some of these treatments. Then how do you incorporate all of that into a more holistic approach, in terms of your offering in the specialty area.

When I talk about pipeline, I try to get plan sponsors to really think about what they’re doing holistically, not just with that particular agent.

It’s interesting to know what’s coming out, but it’s more impactful to understand how it fits in their overall offering to their members.

What are some of the most common mistakes plan sponsors can make?

It’s interesting, because the plan sponsors, I think, had a pretty big jolt with the hepatitis C introduction. That really shook the specialty world up, if you will, with that type of treatment, where you had a cure, and then really high uptake.

What we’re seeing now in terms of the pipeline are innovative treatments that potentially could disrupt current treatment paradigms and carry a big price tag. These treatments may only affect one or two members in their plan but might never been seen by small plans.

What happens a lot of times in orphan diseases is that plans will say, “Well, it’s such a small number. It’s only 20,000 patients in the US. Likely, I won’t have one. I won’t have to think about it.” That’s not going to be the case in the next couple of years.

What we’re going to see is innovative treatments that will hit a broader group of patients. Even though they’re small populations, there will be more treatments to address orphan diseases. Even though it may seem that you don’t have to think about them as much, you probably still do. If it hits your budget, it could be financially crippling.

What I’m going to focus on in the presentation is that even though it’s not millions of people that are affected by this particular disease, all it would take for a small plan of 20,000 members is to have one patient that would require one of these innovative therapies that would potentially put them into financial peril. That might actually be the most common mistakes a plan sponsor could make, is just not thinking that they have to worry about something like that.

What should plan sponsors pay the most attention to when reviewing the pipeline?

Evaluate the information from a market basket perspective. A lot of times, you will see data on a particular agent, and there might be competition within that market.

You’ll never have head-to-head data for each individual competitor, but what you’ll have to do is evaluate what the likelihood is of this agent being used. What patient population would be prompted to use this over what is a current, existing treatment?

We know the inertia to move a patient that is stable on treatment to a new treatment is not high, but what will happen in patients who are refractory, or are not getting enough efficacy out of their current treatment, and what does that population look like?

I think that is what plan sponsors have to pay attention to. Not just that a new drug is coming, but what’s that place in the treatment market basket that they really need to consider for a pipeline agent.

Specialty drugs are driving up health care costs. What steps can plan sponsors take to help offset the burden for plan members?

This is a tough question, because, with innovation comes cost. We know that specialty costs are increasing at an exponential rate.

We know that the prices of specialty medications keep increasing, really, to what the market will bear. Unfortunately, I don’t think our market can bear much more, but we still see these exorbitant costs.

In terms of what a sponsor can do to help offset the burden of the plan member is help guide treatment to low-cost medications that have comparable efficacy. A treatment that the patient will have the best possible chance for a good outcome, but at a lower cost.

Not using, maybe the brand-new drug that comes out, but potentially using tried and true medications that may be at a lower cost, generics, or biosimilars. Those are things that plan sponsors could do to help offset the burden for a plan member.

How can plan sponsors best utilize their relationship with their plan adviser and pharmacy benefit manager?

Make sure that you are communicating what your needs are and what your overall mission and goal is for the members of your plan.

What’s the most important thing for you, and what struggles are you facing financially? What is happening from a benefit plan perspective for the future? Do you have a plan for the next five years, and how can your PBM help you get to that plan?

Then making sure, from a clinical perspective, that you’re talking about the drug pipeline, making sure that you have a strategy in place prior to the drugs hitting the market. Oftentimes, what will happen is, if a drug hits the market often times for a specialty disease where few options exists physicians and clinicians will likely want to use the agent because they may be warehousing patients.

If you don’t have a plan in place, you’re going to get stuck with, “Well, what do we do? There’s demand for it, but we don’t have the strategy for it.” Be prepared and have those discussions ahead of time when you talk about pipeline agents. Where they might fit, where you might cover them, and what criteria you need to have in place.

If someone is unable to attend your session at PBMI’s forum, what’s the best piece of advice you can offer?

The best piece of advice I could probably offer is, look at the drug pipeline with perspective. If you are looking at pipeline agents individually, it would make your head spin because of the development that’s going on right now.

Take it into perspective of what the market actually looks like and what competition lies there. Will the new treatment be something that will revolutionize the market? Does it currently affect anything that is going on within your plan?

If it’s an agent where you know that you have high spend in that area, it’s time to evaluate what you’re doing with your formulary, potentially, or what steps you might need to take from a utilization management perspective.