Trends in Specialty Pharmacy Management

San Francisco—Building on the knowledge base from earlier editions, the eighth annual edition of the EMD Serono Specialty Digest^™ has been released. New and expanded items included in this edition are utilization management, with more detailed analysis of prior authorization and preferred product strategies provided by therapy category; oncology, with strategies related to palliative and end-of-life care identified and prioritized; health outcomes, with input on intervention and outcomes measures for 4 key therapy classes; comparative effectiveness, measuring the impact of comparative effective research (CER) on specialty drugs; healthcare reform, identification of the impact of reform on specialty drug benefits; and trend analysis, measuring and analyzing trends in strategies across previous years.

These and other highlights of the report were presented at the AMCP meeting in a Contemporary Issues session titled Specialty Pharmacy Management Trends: Managed Care Strategies and Outcomes. Debbie Stern, RPh, vice president, Rxperts, provided contracted research for EMD Serono for the project and presented results at the session.

Based on data collected from health plans in the United States, the updated digest provides new information on specialty pharmacy management strategies implemented across pharmacy and medical benefits, strategies related to the management of molecular diagnostics for oncology, and input from payers on outcome measures that impact a health plan’s coverage and formulary decisions for hepatitis C, multiple sclerosis (MS), oncology, and rheumatoid arthritis (RA).

The health plans identified the most important clinical measures for each of the 4 therapy categories. For hepatitis C, the most important measures were achievement of sustained viral response and discontinuation of therapy in nonresponders following response-guided therapy. For MS, the measures were reduction in relapse rate and reduction in disability progression. Reduction in joint damage and reduction in pain and swelling were identified as important measures in RA, and overall survival and progression-free survival were named for oncology.

The top line strategies for oncology management were adoption of National Comprehensive Cancer Network and American Society of Clinical Oncology guidelines for clinical pathways (currently implemented by 51% of plans), promoting use of palliative care and end-of-life programs (42%), working with community oncologists to develop proprietary clinical pathways (23%), adjusting the oncologist fee schedule to encourage use of lower cost drugs (21%), selecting preferred products in some oncology therapy categories (16%), creating pay-for-performance incentives for oncologists for following clinical pathways (12%), outsourcing oncology pathway management to the vendor (9%), and utilizing episode-based payment or bundled payment for oncologists (5%).

When asked about what organizations should primarily be responsible for conducting CER on specialty drugs, 76% of plans chose independent research agencies, followed by federal agencies (76%), pharmaceutical and biotechnology industries (25%), health plans (16%), and pharmacy benefit managers (6%).

The session continued with a presentation from Beckie Frick, PharmD, MBA, senior director clinical pharmacy programs, Blue Cross and Blue Shield of Florida (Florida Blue). Dr. Frick addressed the challenges and opportunities in the area of specialty medication management.

She said there was a lack of consistency in the definition of specialty medications as well as in member cost share for specialty drugs across different channels of the healthcare arena. She stressed the importance of outcome measures in understanding costs and utilization trends, saying “you can’t manage what you don’t measure.”

Oncology has the greatest impact on the drug pipeline,” Dr. Frick continued. There are 400 drugs in the pipeline and 50% of those are for the treatment of cancer. She noted that companion diagnostics and pharmacogenomics are of increasing importance to payers, particularly when used to guide treatment.

She concluded her presentation by providing an overview of the Florida Blue experience with palliative care and end-of-life planning, including use of hospice care. She also mentioned changes in healthcare delivery systems, with implications for specialty medication management.