Industry Experts Tackle Specialty Drug Access Challenges for Employer Benefit Plans

Approximately 65% of workers are covered by self-funded employer benefit plans, according to new data from ICON plc. Discussing the results of the 2023 Employer Health Benefits Survey, representatives from ICON plc, the multinational health care intelligence and clinical consultancy, and Symphony Health, an ICON plc company and an evidence-based, patient-focused health care data intelligence firm, addressed how these plans and the challenges associated with managing them can have an adverse effect on employee access to specialty medications.

At AXS24, the 20th Asembia Specialty Pharmacy Summit, Angela Lawrence, MBA, senior director, Real-World Evidence, Symphony Health; Joe Brown, principal, Medical and Market Research, ICON plc; and Mark McCoy, RPh, MBA, director, Market Access and Reimbursement, ICON plc, together delivered the session, “Employer Influence in Specialty Drug Access.”¹

Lawrence laid the groundwork for the discussion, which encompassed why employers are important to specialty pharmacy and employee and employer concerns about transparency and cost; Brown addressed employer feedback, including their top concerns, from the 2023 Employer Health Benefits Survey; and McCoy rounded out their dialogue on strategic and effective ways to improve employer satisfaction and communication challenges.

Angela Lawrence, MBA | Image Credit: Symphony Health

The Importance of Employers to Specialty Pharmacy

“Self-funding means that employers are actually owning the risk, and with owning the risk, they get visibility to their own claims, and they get visibility to their own transactions for their patients,” Lawrence explained. “This means they can assess how to adjust their plan details for their patients to make those plans more appropriate for them.”

However, she pointed out, with an estimated 8 million employers, 57,000 of whom are thought to be self-funded—of which 62% have between 259 and 499 employees²—lack of communication can be a serious and pervasive issue. This is because intermediaries comprise the primary channel of communication between specialty pharmacy and self-insured employers, which can mean a lack of accurate information on benefits.

Related to this, employers feel they need to provide enhanced benefits to attract and retain employees, with 40% and 44% of employers with more than 500 employees thinking this is important or very important, respectively. So, too, is managing the cost of specialty drugs, with 33% each of employers with more than 500 employees thinking this is important or very important.³ Overall, the most important benefit to employers and employees is health insurance (80%) and health-related benefits (89%). However, only 44% of employees deem health insurance affordable, Lawrence said, and even fewer consider it comprehensive (28%) or convenient (28%).

Lack of data transparency is another chief concern, with 33% of employers and 14% of health plans indicating a lack of awareness regarding time to therapy, only 28% saying they have complete transparency regarding ingredient cost by drug, and just 22% reporting they have full disclosure of all revenue streams with affiliated pharmacy-related entities.^4,5

Obesity is a top concern, too, for all states, per the CDC, and employers have expressed great concern on their ability to realize savings from biosimilars. Data from Symphony Health show despite the increasing availability of biosimilars, biologics still account for 88% of prescription claims.

Joe Brown | Image Credit: ICON plc

Employee Survey Feedback

Explaining why ICON plc chose to conduct the health benefits survey, Brown said, “We looked at all this data from Symphony Health, we looked at some of the industry data, and we thought we should probably talk to employers and get their actual perspectives.”

These companies ranged in size from 30,000 to 350,000 employees and those who responded were from a wide range of industries; health care, energy, retail, and transportation, to name a few. Eighty percent of employers placed high value on the cost of specialty medications to themselves and their employees, 40% did so for employee satisfaction and benchmarking, and 20% deemed access to specialty medications their top priority.

Further, both employee benefits companies and employers prioritize trying to reduce their specialty drug spend and be able to provide benefits that are still attractive and equitable. To do this, they often turn to benchmarking, or looking at their competitors’ offerings.

“We’re always looking at our peers to make sure that we’re in range,” one employer replied.

Employers’ top disease areas of concern in the specialty market (88%) are obesity, oncology, and diabetes medications when they are building out their benefits plans and making employee benefit decisions; 75% ranked musculoskeletal conditions as their top disease state of concern; and 50%, cardiovascular and pulmonary/asthma. In particular, they reported wanting more information on the impact of obesity drugs and how their competitors are managing these costs.

Overall, they decry the lack of visibility/transparency and understanding of the data they require to support their benefits decisions—including that on biosimilar-related savings, effectiveness, and market presence—especially regarding claims, rebates/discounts, and prescription fill time, abandonment, and denials. They want to know more about how they benchmark against their competitors, where there are opportunities to improve coverage and cost savings, potential cost offsets (ie, lifestyle programs), and year-over-year data on claims, patient populations, and costs to help with their plan design.

Mark McCoy, RPh, MBA | Image Credit: ICON plc

Improving Employer Satisfaction

Through the ICON plc analysis, McCoy noted several key areas were identified that were key to improving employer satisfaction: communication, emphasizing the economic story, and improving employee satisfaction.

“Even more important than the current cost of health care and the cost of specialty drugs to the employers is attracting and retaining talent,” McCoy said. “Employers want to keep that talent, they want to attract employees, and when they do, they want to keep them happy.”

Communication needs to be direct and unfiltered, and it should be high level in that it addresses what is important to those employers. It also should target what’s important to both employers and employees and should not be delivered through pharmacy benefit managers (PBMs) or intermediaries, “because they will only emphasize what differentiates them from another PBM,” he added

Addressing emphasizing the economic story, McCoy noted that employers have indicated they are receptive to learning more about potential savings related to biosimilars, with almost half of the current drug spend (45%) tied up in biologics and reference drugs continuing to be used 88% of the time. Biosimilars, he said, have potential to save costs in the billions, and due to this, employers are eager to explore new ways of doing business in the specialty market. But they want to see the evidence, especially patient-reported outcomes data, of how a brand or service will improve their employees’ satisfaction.

“Employers may be your biggest customer,” he underscored.

References

1. Lawrence A, Brown J, McCoy M. Employer influence in specialty drug access. Presented at: AXS24; April 28-May 2, 2024. https://asembia2021.egnyte.com/fl/u6bmUePsTR#folder-link/AXS24%20Session%20Slides?p=2774410c-b2e6-4391-b466-3850cbdffc7a

2. Number of employer business establishments in the United States in 2021, by number of employees. Statista. November 3, 2023. Accessed May 1, 2024. https://www.statista.com/statistics/254085/business-establishments-in-the-us-by-employment-size/#:~:text=In%202021%2C%20about%204.6%20million,over%201%2C000%20employees%20were%20registered

3. Mercer’s 2022 National Survey of Employer-sponsored health plans

4. 2023 Trends in Specialty Drug Benefits Report. Pharmaceutical Strategies Group. Accessed May 1, 2024. https://www.psgconsults.com/industry-report/2023-trends-in-specialty-drug-benefits-report/

5. Pulse of the Purchaser 2023 Survey Results. National Alliance of Healthcare Purchaser Coalitions. December 13, 2023. Accessed May 1, 2024. https://www.nationalalliancehealth.org/resources/pulse-of-the-purchaser/