Managing Specialty Drug Costs Among Many Challenges Ahead for Health Plans

Figuring out ways to rein in the escalating costs of specialty drugs, the GLP-1s and TikTok and the possible of drawbacks of having numerous biosimilars to Humira on the market were among the topics discussed at the opening session of the 2023 PBMI Annual National Conference.

Matthew Lee, vice president of sales and marketing at MedOne, a pharmacy benefit manager (PBM) for self-insured employers, led the lively discussion about trends in care management from a PBM and health perspective. He was joined about Ellen Feeney, Pharm.D., director of clinical pharmacy strategies at Highmark, one of the largest Blues plans in the country, and David Eckwright, Pharm.D., M.H.I., a senior director of specialty analytics and informatics at Prime Therapeutics, a large PBM that is owned by Blues plans.

The panelists agreed that managing specialty drug costs, which now make up about 50% of the spending on prescriptions, requires more than just the traditional pharmacy benefit management tactics, such as prior authorization and utilization management.

Feeney, whose group at Highmark oversee formulary and utilization management decisions and policies, nonetheless analogized them to using a sledgehammer to fix a leaky faucet. “There are others, tools like case and care management, and channel management. And then, looking at those high-touch members, and how do we manage them in a way that is most effective for our health plans,” she said at the Wednesday afternoon session.

Feeney noted, for example, that Highmark has a nurse devoted to hemophilia care: “That’s all she does — care management for hemophilia patients.” She added that her employer has a specialty management team that works with specialty pharmacies and a population health team that works directly with physicians.

“So it's really just using whatever tool makes sense in the situation,” Feeney said. “It might be multiple tools.”

She also mentioned that Highmark has pharmacists on its case care management for about eight years. “They work directly with members on questions from everything from ‘I can't afford my copay” to ‘Is this a side effect of a drug’ and what can I do about it?”

Eckwright chimed in with short description of a program at Prime dubbed “high touch Rx,” which he said started as a pilot project involved pharmacists “hunting and pecking” through claims data to identify cost-savings opportunities among members taking specialty drugs. He said that advanced data analytics have been layered into that project, which he said had “blossomed” into a “post payment management solution where we can surveil the use of specialty drugs and find situations where action can be taken to reduce costs in the near term.” The savings opportunities include “dose consolidation,” he said. With dose consolidation, rather than taking many small doses of a drug, which can be expensive because of how small doses are priced, the PBM encourages providers to prescribe larger doses of the same drug, a change that can save money but also be more convenient for patients because they might need to take just one pill a day instead of several.

Eckwright said seven-figure cell and gene therapies have employer groups focusing on questions about their effectiveness. Once coverage is approved, patients are immediately “swept up” into care management programs and afforded lots of support to “give the drug the best chance (of working) — that they (health plans and patients) get those outcomes, just due to that high cost.”

Eckwright also noted that the time horizons are very important in gauging these drugs and developing care management programs and expectations for a return on investment. He said he has seen a lot of adoption of short-term time horizons. He also noted that federal government’s Stars program and others like it can throw things off and “shake things up “ in standard return-on-investment calculations because Stars and programs like it may reward health plans in the short term for utilization patterns that may not demonstrate a return of investment till years later.

The conversation also touched on biosimilars. The panelists agreed that they could help reduce costs but also discussed some of the pitfalls. Feeney said the number of Humira biosimilars — there are currently nine approved and eight that have been launched on the market — could create a scenario whereby every health plan and pharmacy is going to prefer or stock different products. “That's going to create a complete and total nightmare for our members trying to get access to these medications, Feeney said.

Feeney opened the session with her observations about e GLP-1 drugs, a class of diabetes and weight loss drugs that includes Ozempic (semaglutide), Wegovy (semaglutide) and Saxenda (liraglutide). The GLP-1 drugs are the “elephant in the room that everyone wants to hear about,” she said. As a clinician, Feeney is a fan of the drugs: “I think they're good drugs. I think they're great drugs, as a class, as a whole.” But she also said they are a harbinger of drugs that will be effective and serve a need but expensive.

“How do we responsibly provide access to these medications without breaking the bank? I don't necessarily have an answer. But I challenge everyone in this room that we're going to have more products like this, that work, that are really good drugs that have a wide variety of indications and possible or possibilities. And I think we're really just ramping up with the GLP ones,” Feeney said.

Lee said the small to mid-size employers that are MedOne’s clients are “really pressured on what to do with the available dollars they have, and it's limited.” The company’s pharmacist team recommends that a wellness or weight loss program be included with GLP-1 coverage. “Just the introduction of Wegovy or Saxenda or whatever the drug is, it doesn't mean that that's just a magic pill and they can forget about the diet and exercise that should go along with that,” he said.

Lee also noted that off-label use of Ozempic took off partly it trended on TikTok.

“If any of us were to stand here last year and predict, hey, I think there's going to be a TikTok trend that's going to make a drug go viral, you all should be doing things to predict the future because I don't think any of us would have thought that can impact the industry the way it did to the point where there was a shortage of a medication to treat diabetic patients who needed that medication,” Lee said.

Such surprises are going to happen, Lee said. “There will be a surprise next year that everyone's talking about, and the following year. (The question is) how can we address it and help our clients navigate, because it will be a challenge.”

This article originally appeared on Managed Healthcare Executive.