Neil B. Minkoff, MD: Let me throw a wrinkle in this. We’ve been talking about the overall cost of care. We talked about the study looking at ocrelizumab, but there’s going to be a new self-injectable in this space, ofatumumab, and that’s going to be out any day now. How does that potentially affect the way you might look at this class to have another self-injected drug in the market, Eric?

Eric Cannon, PharmD, FAMCP: That’s a great point, Neil. Looking at an additional entrant self-injectable, it comes down to what those net costs are and how we look at that. We can have a new self-injectable come to market, and if they launch at the same price as their competitors, we may have no net gain in what’s going to happen. Whether it’s self-injectable, whether it’s oral, whether it’s infused at home, whether it’s infused in the clinic, or whether it’s infused in an outpatient center, understanding everything that goes along with that is important. Its laboratory tests and associated imaging as well as the office staff time around that all factor into it all. We can’t just say, “Oh, goody, we have a new self-injectable.” We need to take a step back and look at how that is going to change the cost structure. It’s not just about how it changes the cost structure, but is it more effective? Do we have fewer exacerbations? Do we have fewer hospitalizations? Maybe we’re spending the same, but now we’re spending a lot less on other associated medical costs than we were previously.

Kevin U. Stephens Sr, MD: I’d like to say something too.

Neil B. Minkoff, MD: Kevin, please.

Kevin U. Stephens Sr, MD: It’s a good point because the different medications and even the route of administration can lead to, for instance, skin infections or wound infections from the site of the infusion. As you infuse this, if it leaks into the skin and so forth, it can cause all sorts of problems, as well as compliance and the adverse-effect profile. Some medications have many more adverse reactions, which will cause ER [emergency department] visits and the like. We have to look at the big picture to figure out how to help guide what we do and how we administer these drugs.

Neil B. Minkoff, MD: Michael?

Michael Fine, MD: Getting back to the point we made earlier about whether it makes a difference whether something is self-administered or infused, we said that the most important thing is that the efficacy and safety are similar. You’re not going to want particularly a patient with MS [multiple sclerosis] to receive an inferior drug, but this is a good example where you’ve got 2 drugs, ofatumumab and ocrelizumab, that have the same mechanism of action. Based on the data, they look like they’re similar in terms of efficacy. This may be a situation where, because of the higher total cost of care with ocrelizumab, we will consider preferring ofatumumab. It will take time because it’s a new drug, and everybody has to see how well it performs in the real world. That’s a good example where that difference may be the tiebreaker where we’ll go with the subcutaneous drug.

Neil B. Minkoff, MD: This brings us back to the management across the different benefits. How would you prefer these, with 1 flowing to the medical benefit and the other flowing to the pharmacy benefit? How do you make sure they’re all being routed through the same channel for utilization management?

Michael Fine, MD: For us [with Health Net of California], they are routed through the same channel. The operational process is the same. Whether they request ocrelizumab or ofatumumab, they’ll have to go through the same process, and that process can have a step edit to prefer the subcutaneous drug.

Neil B. Minkoff, MD: Kevin, please.

Kevin U. Stephens Sr, MD: Another point is that it has to do with risk sharing or risk transfer, however you want to label it. For the provider, we call the care organizations or those types of organizations where it’s a whole network together, and we let them figure it out. You have to figure out what the best way for your system is because the cost is shifting to them to make that decision.

Eric Cannon, PharmD, FAMCP: Neil, 1 of the things you run into that’s critical is that, as we look at this, we’ve had varying trends over the years where it was about carving pharmacy away from the health insurer to a PBM [pharmacy benefit manager]. Then, for a period of time, it was about integrating care all back together with the health plan. We now see ourselves going backward in that we carve out care management. Let’s put a care navigator on top of it. Let’s find another PBM. As you silo that care, you move it out to the different vendors.

It’s critically important that we as carriers absolutely understand that because there are people in the market saying that there’s something different from what we would like to receive in terms of how the benefits are managed. It’s critical for employers, clients, and others to realize that, as care becomes more fragmented as you put it through various different vendors, you run into those silos and those minor or even major perverse incentives that may be driving them to do 1 thing or another, which may not be driving to a total low-cost care or the best care that could be delivered to a particular patient. As I look at this and talk to our clients and our employers, if you see something that’s better in the market, talk to us about it and help us bring our programs and things along. Although you may achieve some short-term savings by carving out or adding another vendor on top of things, we again fragment care. We misalign the incentives, and we lose that opportunity to provide a low-cost comprehensive product that’s going to deliver the best outcomes for our patients.