As the pipeline of costly—yet sometimes life changing—specialty drugs continues to grow, payers need a nimble partner with a proven model that controls specialty costs and improves patient health.
1| Condition-Focused Clinical Controls
The complexity of specialty medications and the diseases they treat require a customized clinical approach that carefully balances clinical effectiveness, the economic impact to the plan and the impact on the patient experience.
As payers design their plan and cost sharing model, they must ensure that patients can afford their critical medications, and create ways to incentivize utilization of the lowest cost options. Utilization management techniques and formulary exclusions are also an effective way to manage specialty, but not all approaches yield equal results.
Within a given therapeutic class, different drugs may need different prior authorizations or additional step therapies. In some instances, split fills and outcomes-based performance contracts are helpful, while in others, they are not.
The best management of specialty medications starts with a plan design that includes clinical controls tailored to the disease state and the drugs available for them.
2| Individualized Care
The proliferation of many therapies for a single disease state is a testament to the complexity of these conditions, which often manifest differently from patient to patient. For example, one multiple sclerosis (MS) patient on one therapy can respond very differently than another on the same therapy due to the nature of the disease.
Adherence rates for specialty medications often decline for reasons ranging from affordability and side effects to accessibility. Additionally, there is potential for duplications of therapy and contraindications with other drugs, especially pain medications, that need to be considered.
Before starting treatment, it needs to be determined if the prescribed treatment is a good fit for the patient, including evaluating dosage levels relative to their age, body mass index and even genetic makeup. Additional discussions should include the best time to start therapy, how to mitigate side effects and treatment expectations.
Successful specialty pharmacy management requires a partner who can help patients better understand and have confidence in their treatment options.
3| True Integration
On average, a patient with one chronic condition sees four providers per year, while those with five or more chronic conditions may see 14 different providers a year. This could lead to patients leaving the doctors’ offices with multiple prescriptions and filling them at different pharmacies, sometimes through their medical benefit or cash pay.
As a result, payers have only a partial view of the patient’s prescription utilization, which can lead to significant risk for multiple care gaps and further increase costs. Research shows that poor care coordination raises chronic disease costs by $4,500 per patient.
Well-integrated PBMs and specialty pharmacies outperform peers on cost control and health outcomes. They share data and systems in a way that provides visibility into utilization history, claims processed through any pharmacy and benefit coverage (i.e., step therapies).
True integration enables all care coordinators to work together to best manage the patient, while providing better, data-driven, personalized clinical guidance.
4| Meaningful Data
Raw data can provide numbers regarding outcomes and plan performance, but real insight comes from seeing trends and taking action to reduce costs and close care gaps like abandonment, disease progression, duplication of therapy and incorrect dosages. This is often an overlooked piece of the specialty pharmacy puzzle.
Because specialty patients see a lot of providers, many traditional pharmacies do not have the information they need to identify and close gaps in care or share options for less expensive alternatives. For example, pharmacies may miss dangerous drug combinations and often times patients do not receive a suggestion for lower cost alternatives.
Our High-Impact, High Touch Approach to Specialty: MS In The Real World
Our unique approach to specialty care optimizes all aspects of the pharmacy care experience. Pairing the collective clinical expertise of our nationally recognized drug therapy management and specialty pharmacy with our industry leading technology platform, we enable the design of more affordable, condition-focused benefits and deliver the highly individualized care required to effectively manage complex conditions like MS.
Since MS is a nervous system disease that takes time to diagnose and slowly progresses, having a multi-step formulary design gives licensed neurologists more options to tailor treatment plans. For patients in stable condition, therapies should be grandfathered to protect their current state of health and avoid plan sponsors incurring over $13,000 per relapse in additional medical care.
Since certain specialty medications have troublesome side effects after the first dose, treatment-naïve patients need a strategy to start therapy successfully. Our Care Navigators, specially trained clinicians, use our proprietary patient engagement tool to identify and resolve individual barriers to adherence, like lifestyle, financial and genetic factors, and help patients choose ideal start dates for their new treatment. For all MS patients, our unique Disease Activity Tracker continuously monitors six key areas of risk that define the frequency and type of outreaches patients receive and recommendations for when repeated imaging should be conducted.
With access to the same claims’ technology platform, we are able to tailor care for each patient, as well as provide more robust reporting on plan performance and share recommendations specific to your business goals. While typical abandonment rates in the first 90 days of MS therapy are high, our EnvisionCare model produces early discontinuation rates less than 5%, generating industry leading outcomes and plan savings.
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 Vogeli et al. (2007) Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality, Care Management, and Costs. Journal of General Internal Medicine.
 Frandsen, Joynt, Rebitzer et al. (2015). Care Fragmentation, Quality and Costs Among Chronically Ill Patients. American Journal of Managed Care.