Dr Brian MacDonald on Enhanced Utilization Management Programs for Rare Disease Treatments

At the Academy of Managed Care Pharmacy Nexus 2022 fall meeting, Brian MacDonald, PharmD, senior director of specialty clinical strategy and innovation at Magellan Rx Management, explains how enhanced utilization management programs are implemented and how they can lead to cost avoidance for rare disease treatments.

Transcript

What are some enhanced utilization management programs for rare disease treatments that are currently available to payers?

Currently, companies like Magellan Rx have started to put together some more enhanced next-generation utilization management programs to help payers and providers alike sort of navigate these new and evolving treatments for rare diseases—kind of moving past the traditional prior authorization process or other standard clinical reviews and into a more in-depth, nuanced, and specific review process for each condition and each rare disease.

How can these lead to cost avoidance, and why is that so much more important than savings?

I think it can lead to cost avoidance in a couple of ways. First of all, given the continually rising costs of some of the treatments that are coming out for these rare conditions, even just 1 or 2 instances or good catches of prevention of inappropriate use has the ability to generate significant ROI [return on investment] for payers.

I think cost avoidance is a more important outcome over savings, because the goal of these enhanced utilization management strategies and programs is not to just drive savings for the sake of savings. The idea is to present a comprehensive and clinically sound approach to evaluating these treatment requests for these rare diseases. When you talk about cost avoidance, you can be potentially talking about the difference between a requested treatment and potentially a more cost effective alternative, and you may be also talking about sort of the long-term incremental of cost avoidance for some of the downstream and long-term effects of these rare conditions as well.

How have such enhanced utilization management programs been implemented in the real-world, and what results have you seen?

Personally, I've been fortunate enough to spearhead programs like this for Magellan Rx. Especially over the last 2 years, we've been able to implement programs such as this for a number of our health plan clients. And, as a result, as the years progressed and we see larger and larger volumes of requests for various treatments across a number of different rare diseases, we are seeing great results in terms of the cost avoidance. We're seeing transparent review processes with the requesting providers—so there's open communication back and forth—and we're also able to generate a lot of member outreach on the back end. So, a lot of these rare disease patients are getting outreach from their respective health plans to talk about their medication lists, their diagnoses, and making sure that they're getting the full spectrum of care that they that they so desperately need.