Many effective strategies exist when it comes to managing specialty drug costs, but a coordinated approach that takes the financial, clinical and pharmacy elements into account is key to achieving a balance between access and spending, according to Telus Health’s Cory Cowan.
Cowan, the organization’s director of professional services, told attendees at the 2018 Pharmacy Solutions in Drug Plan Management Forum in Mississauga, Ont. on Sept. 25 that recent Telus Health data showed specialty drugs — those costing more than $10,000 per patient per year — made up 27 per cent of total eligible costs under private plans in 2017, representing just one per cent of all claimants. This is up from 11 per cent of eligible costs in 2008.
Similarly, the number of high-cost drugs impacting private plans has also increased dramatically, from 23 drugs in the $10,000-plus range on the market in 2005 to 163 in 2017.
In addition to the magnitude of new drug approvals, there are a number of challenges in managing specialty drug costs, according to Cowan, who referred to complicated administration, limited distribution and increased monitoring requirements.
As a result, specialty drug management strategies aim to maintain access and improve patient outcomes while ensuring money is well spent, he said, and encourages stakeholders to ultimately “see these specialty agents as an investment, rather than just a cost centre.”
This often requires a three-pronged approach, said Cowan, which includes financial, clinical and pharmacy management.
Financial management, he said, may involve drug markup caps, maximum allowable costs or annual/lifetime maximums, although he noted there may be unintended consequences to consider when implementing caps.
“There is some research to show that patients who hit their caps, or plans that have implemented caps, have had worse outcomes, and in some cases they’ve had poor adherence rates, more hospitalizations, ER visits and in even some cases, death. So I think it’s an important balance to think about financial management versus what the outcomes for the patient are.”
In terms of clinical strategies, a managed formulary is one effective solution, noted Cowan, as it allows for proper comparative and cost-effective analyses — clinical and economic — from a private payer lens, allowing them to identify drugs that provide good value for money.
“I think this is probably one of the better options to manage specialty drugs, but is unfortunately one of the most under-utilized.”
Prior authorization/step therapy, said Cowan, is the most commonly used clinical strategy for managing specialty drugs. And there’s been an evolution in recent years where many plans are starting to not only confirm the approved indications, but are incorporating step protocols and encouraging first-time patients to start on biosimilars.
At the same time, prior authorization is an overly manual and cumbersome paper-based process, he noted, and steps should be taken to automate the process to allow faster access for patients, linking the physician to the insurer and the pharmacy.
Cowan pointed to biosimilars as “the biggest opportunity for plan sponsors moving forward in terms of managing specialty drug costs.”
At the same time, he acknowledged there are challenges to increasing their adoption in plans. These include lack of interchangeability, which prevents a pharmacist from interchanging an originator molecule with a biosimilar at the point of sale, and the availability of patient support programs that help cover any financial gap the patient may experience by staying on the originator molecule.
As such, said Cowan, biosimilar use can best be encouraged by formulary placement, prior authorization/step protocols, maximum allowable cost, as well as aligning a biosimilar strategy with the specialty pharmacy and physician/plan member education.
“There’s still a lot of misconception on how a biosimilar compares to its originator molecule, and I think having those messages out to your plan members, encouraging the safe and effective merits of those products is important for their adoption,” he said.
On the pharmacy management side, Cowan noted specialty pharmacies go hand in hand with patient support programs, as specially trained individuals guide patients through their care, track clinical outcomes and ensure the patient is getting the best outcome from their therapy.
In the future, Cowan sees specialty drug management trending towards electronic prior authorization; a better line of sight in terms of forecasting the drugs coming down the pipeline; pharmacogenomics; and linking the outcomes of these patients back to productivity and reductions in short and long-term disability.
Ultimately, he said, a coordinated approach allows for balance between providing access to high-quality and effective products while ensuring costs are properly managed.
“Having a multi-pronged approach for specialty [drug] management is important, doing one single thing is not going to be enough, and you really need to take advantage of all these different pieces,” to be successful, noted Cowan.
Read more articles from the 2018 Pharmacy Solutions in Drug Plan Management Forum