Getting the most out of what’s spent on employee benefits plans is an ongoing challenge for drug plan sponsors. In May, nearly 200 drug plan stakeholders gathered in Vancouver for the third annual Face to Face Drug Plan Management Forum, where industry experts discussed the latest drug plan trends and offered ideas for managing costs and improving health outcomes.

With a stream of new biologics coming to market, a wide variety of programs and services are available to support patients taking these high-cost specialty drugs. A panel discussion moderated by Michael McClenahan, CEO of Benefits by Design, explored the pros and cons of these new programs and their impact on private drug plans.

To start, the panel pointed out differences between manufacturer- and payer-provided programs. Kevin West, vice-president of Innomar Strategies Inc., put it simply by describing the main goal of manufacturer programs: getting patients on the drug quickly, taking the drug properly and staying on the drug. These programs, which typically focus on one specific drug, run the gamut, from providing reimbursement assistance to connecting the patient with nursing services, scheduling infusions at injection clinics, having pharmacies dispense the products and providing compliance reminder calls.

Payer programs, on the other hand, focus on ensuring the right drug is there for the right patient at the right time, West said. Since the payer’s objective is to minimize costs, their programs may include preferred provider networks (PPNs) for lower drug markups, prior authorization to help ensure it’s the appropriate drug, and case management to monitor patients and ensure the best health outcomes for the investment.

Representing the insurers’ perspective, Joyce Wong, manager of pharmacy services for Pacific Blue Cross, stressed that many plan sponsors are moving to more restrictive plans to keep their plans sustainable. “We have to follow the contracts, and there isn’t always an avenue to cover the drug for the patient,” she said. “To get patients on assistance programs, it’s important to ensure that it’s the right drug for the right patient at the right time.”

Patients who start treatment with a specialty drug are often overwhelmed and face many barriers, said Kathy Sotirakos, senior market access manager, private insurance, with Amgen Canada Inc. “Reimbursement is a significant hurdle, and navigating the requirements can be very daunting for a patient who’s just been diagnosed with a life-threatening disease,” she explained. “Over the past 10 years, patient assistance programs have changed a great deal based on what we’ve learned from patients, physicians and the healthcare community. Without these programs, there would be a lot of patients without support and the progression of diseases we don’t want to see advance.”

Dr. John Wade, clinical associate professor with the University of British Columbia’s Division of Rheumatology, added that the quality of patient programs is at a very high level across the board now in terms of providing patient education, offering financial assistance and managing compliance issues. “There are opposing views in the industry, with the manufacturer side giving drugs to the patient and the insurer side at the opposite end of the continuum. They both say they’re helping patients, but the reality is that insurers want to minimize costs. You have to find a way to balance the two.”

Although he likes the idea of patient assistance programs supporting certain aspects of a patient’s specialty drug therapy, Wade stressed the need for ensuring patient care remain with physicians, nurses and pharmacists in the local community. “To have a surrogate somewhere else directing patient care could mean trouble for the patient. Streamlining is going in the wrong direction, and the patient could end up with the wrong drug and have complications.”

But Chris Dalseg, director, business development, with BioScript Pharmacy Ltd., sees a need for more streamlining of patient support services. “We’re entering a new time where there are, increasingly, more parties that want to be involved in the patient’s care,” he explained. “Now you have manufacturer-sponsored support programs calling patients to help them work through the program, carriers calling to validate the prior authorization requirements, and pharmacists calling to talk about the drug and disease state to help them manage their therapy. Perhaps there is an infusion clinic involved as well, so someone has to book that appointment. So, there are, increasingly, more and more contacts with the patient, and that can be challenging when they’re already overwhelmed. Over time, we’ll have to figure out how to streamline everything,” he said.

“While more co-ordination between stakeholders may improve the patient experience, the positive impact of patient support programs on compliance, productivity, absenteeism and disability is already self-evident,” said Anthony Halket, BioAdvance manager, with Janssen Inc. “We have conducted patient surveys that demonstrate this, including measuring the impact of our program on patients’ time off work, as well as patients’ perceptions of the value of the program. Ensuring patients contact the manufacturer-sponsored patient support program when they are prescribed a specialty drug is important, not only because we have a wealth of information on the treatment, but also because we offer a host of services meant to help patients optimize that treatment. For employers, this can potentially lead to less absenteeism, lower disability and higher productivity.”

All the articles from the event can be found in our special section: Face to Face Drug Plan Management Forum coverage.

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