Opportunities in Utilization Management: Making Specialty Drugs Affordable

When it comes to managing chronic conditions and rare disease, the cost of treatment can be astronomical. Fran Gregory, PharmD, MBA, director of specialty pharmacy, Humana Pharmacy Solutions, offered her solutions to PBMI attendees, saying there are a variety of options to manage the rising costs of specialty drugs. Dr Gregory suggested that savings opportunities for providers, payers, and patients must include considerations such as utilization management, cost-effective delivery channels, and increasing adherence among members.

Dr Gregory says that utilization and inflation are related. Because there is a small population afflicted with chronic illness and rare disease, the cost to produce these prescription drugs is spread out among a smaller amount of patients. As inflation increases, so does the cost. For instance, one multiple sclerosis drug cost about $1500 in 2007. Today that same drug costs $4600.

She went on to describe that when managing conditions like chronic myeloid leukemia (CML), adherence greater than 90% was more than often a result of major molecular response or complete molecular response system requirements. She said strong adherence ensures that the prices of costlier specialty drugs do not go wasted—providers want to make sure that patients are taking medications as prescribed to order to improve outcomes.

To drive this level of adherence (>90 %) requires a system of alignment. The pharmacy benefit must align with the specialty pharmacy, and both must align with the medical benefit. Dr Gregory says aligning pharmacy and medical policy is important to lowering costs not only in specialty drugs but on high-priced assessments such as pharmacogenomic tests.

Other conditions such as rheumatoid arthritis and hepatitis C also require the development of better clinical management programs to control costs and drive adherence. A better management program would let patients know what to expect. In hepatitis C, for example, as more drug classes are developed, more leverage and options for managing the condition are provided. Dr Gregory says challenges lie ahead, but “We are gaining coverage in this space.”

Overall, she says, there is a 3-stage approach to making specialty drugs affordable: aligning the strategic management of medical, pharmacy, and special pharmacy.

Stephanie Holliday, PharmD, senior director of clinical operations for AcariaHealth, who co-presented with Dr Gregory, said there are trending outcomes in the management of MS with the newly approved oral agent, Tecfidera. AcariaHealth’s care management program utilizes such treatments to produce outcomes that provide cost savings. Underscoring Dr Gregory’s focus on medication adherence, she suggests that collaboration through patient portals and Web-based tools like AricaConnect is vital.