The Official Medtipster Blog

have your healthcare and afford it, too
Subscribe

The Importance Of Specialty Medication Management

January 03, 2013 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News, Prescription Savings

www.Medtipster.com Source: Navitus Clinical Journal, Vol. 9 – January 2013

Approximately one to five percent of the population uses specialty medications. Nonetheless, spending for specialty medications has increased between 15 and 20% for the last several years and is expected to represent up to 40% of an employer’s total medical spend by 2020. Controlling specialty medication cost is therefore a critical focus area for plan sponsors. With more and more specialty drugs coming down the pipeline, it will be increasingly important for plan sponsors to manage this area of their drug spend.

Managing this highly complex area involves coordination among multiple parties, including plan sponsor, pharmacy benefit manager (PBM), medical administrator, specialty pharmacy and the patient.

Benefits of Specialty Drug Control
Growth in specialty spending is expected to outpace non-specialty spending due to:

  1. High proportion of newly approved drugs in the specialty market
  2. Complex and expensive manufacturing processes
  3. Limited competition within specialty medication therapy classes

It is clear that plan sponsors can benefit from managing specialty costs. While specialty medications may represent a low percentage of the drugs purchased by the plan sponsor’s members, the cost of these medications represents much more than the actual percentage of medications purchased.

In addition to cost control, helping members adhere to their regimens with specialty medications is essential, as high adherence rates have been shown to reduce hospitalizations, promote better health outcomes and lower overall health care costs.

Ways to Manage Specialty Medications

1. Implement a Mandatory Program

We recommend that plan sponsors implement a SpecialtyRx program as mandatory for members with specialty needs. Specialty programs coordinate personalized support for patients impacted by chronic and complex diseases, such as rheumatoid arthritis, multiple sclerosis and cancer. Such diseases often require complicated medication regimens that include specialty medications. By mandating use of a specialty pharmacy vendor, plan sponsors reap the benefits of reduced drug discounts with specialty pharmacy partners (versus the typically higher retail pharmacy pricing), superior clinical oversight, and individual member case management

2. Incorporate a Split-Fill Program

A  Specialty Split-Fill Program reduces days’ supply to 15-day intervals for qualifying high-cost specialty medications that typically have high discontinuation rates within the first three months of therapy. This prevents unnecessary dispensing of two weeks of therapy, should therapy be discontinued within the first half of the first three months of a prescription. This program also allows specialty pharmacy to initiate earlier clinical interventions due to medication side effects that require dose modification or therapy discontinuation. According to the May 2012 issue of Managed Care, a health plan with about 500,000 members saved approximately $300,000 in its first year with a split-fill program.

3. Know your Specialty Costs Through Pharmacy & Medical

Plan sponsors should equip themselves with information about their specialty drug spend and track specialty costs not only through their PBM but through their medical vendor as well. Less than 20% of health plans and employers currently receive reporting from their PBMs or other health care vendors on medical specialty utilization. Given that plan sponsors identified specialty drug costs as one of their two most important outcomes for specialty management, and that 50% or more of the specialty spend resides on the medical side, this gap represents a critical area of opportunity.

4. Managed Specialty Programs relieve clients of the burden of managing their specialty populations and assume this responsibility through a comprehensive, patient-centric program that offers:

  • Built-in utilization management edits (e.g., prior authorization, step therapy) to ensure members use lower cost specialty products, where appropriate.
  • Continually negotiated lower discounts with specialty pharmacies.
  • Price increase protection built into rebate contracts for specialty drugs, where available, to account for price inflation; that is, when certain products increase in price, rebates for those products automatically increase as well.
  • Continual monitoring of new drugs entering the pipeline. Their Pharmacy & Therapeutics Committee will continue to monitor and evaluate specialty drugs, including any biosimilars being released. Biosimilars are products that are chemically similar to other products; very few have received FDA approval at this point. We expect biosimilars will be significantly less expensive than their specialty brand medication alternatives and will play a bigger role in controlling specialty trend in the future.

As an example, a plan sponsor’s employee has a very expensive specialty medication. This specialty drug utilization represents less than 2% of total utilization, but accounts for, on average, half of the plan sponosor’s drug spend. The previous discount for the drug was under 20% off the average wholesale price. After its transition to a managed specialty program, the discount for this drug rose to 47% off the average wholesale price, providing a savings of more than $140,000 in the first three quarters.

How to Begin to Control Specialty

If you do not currently use a mandatory program, talk to your provider today to implement the program. Plan sponsors can reap the benefits of  preferred pricing via a specialty pharmacy, and their members can benefit from the one-on-one specialized care from the case managers available through  specialty pharmacy vendors.

Be proactive and take control of this sector of your plan’s drug spend. By maintaining a tightly managed specialty program, not only will plan sponsors benefit from reduced costs, but their members will also benefit from improved overall health.

Flu Season’s Approaching So Roll Up Your Sleeve

September 28, 2012 By: Nadia Category: HealthCare, Medicine Advice, Medtipster, Prescription News

www.Medtipster.com Source: HealthDay, 9.27/12 – By Steven Reinberg

 The only thing predictable about the flu is its unpredictability, U.S. health officials said Thursday, as they urged virtually all Americans to get vaccinated for the coming season.

Even though last year’s flu season was one of the mildest on record, that’s no sign of what this season will bring. It was only two years ago, officials noted, that the H1N1 pandemic flu swept around the world, sickening millions.

“The last several years have demonstrated that influenza is predictably unpredictable,” Dr. Howard Koh, assistant secretary for health at the U.S. Department of Health and Human Services, said during a morning news conference.

“Even mild seasons can lead to suffering and death,” Koh added. “Sadly, last year there were some 34 influenza-associated pediatric deaths.”

Every year an estimated 5 percent to 20 percent of Americans come down with the flu, leading to 200,000 hospitalizations — including 20,000 children under age 5, Koh said. And over a 30-year span, from 1976 to 2006, estimates of flu-related annual deaths ranged from a low of about 3,000 to a high of about 49,000.

This year’s vaccine contains the same strains as last year’s, plus two new strains — one for a new influenza A virus and another for a new influenza B, Dr. Daniel Jernigan, deputy director of the U.S. Centers for Disease Control and Prevention’s Influenza Division, said at the news conference.

“More than 85 million doses of flu vaccine have already been distributed and more is on the way,” he said, adding that about 170 million doses are expected to be available.

“The best time to get vaccinated is before the flu season gets started,” Jernigan said. “Everyone 6 months and older is encouraged to get vaccinated.”

The typical flu season runs from the fall through early spring.

Koh stressed the vaccine is safe and has only mild side effects. Because the flu is different each year, the vaccine needs to be revised to keep up with the circulating strains.

Despite the low level of flu activity in 2011-2012, about 42 percent of Americans got vaccinated, which is about the same as for the previous flu season, according to CDC records.

Among children, some 52 percent were vaccinated last year, compared with 51 percent the year before, Koh said. Vaccination rates typically drop as children get older, he noted.

For children 6 to 23 months old, almost 75 percent were vaccinated during the 2011-2012 flu season, compared to just 35 percent of teens, Koh said. “We were pleased that, for kids, for the second year in a row there were no racial or ethnic disparities in coverage,” he said.

But when it comes to adults, “there is much room for improvement,” Koh said. “Last year about 39 percent of adults were vaccinated, compared to some 41 percent the year before,” he said.

Vaccination is important for all adults, but particularly for those with conditions such as asthma, diabetes and heart disease, which can leave them susceptible to complications from flu, Koh said. “Coverage among these high-risk adults was only 45 percent last season, compared to 47 percent the season before,” he said.

While there were no racial or ethnic disparities in vaccination rates among children, disparities remained among adults, he said. Whites, American Indians and Alaska Natives had the highest vaccination rates at 42 percent, while Hispanics had the lowest rate at 29 percent, he said.

On the plus side, more pregnant women are getting vaccinated, Koh said, noting that pregnant women are at greater risk of complications from the flu. What’s more, a mother’s immunity can protect her newborn for the six months before the child is old enough to be vaccinated.

Koh also reported that last year 67 percent of health-care personnel were vaccinated, but there were major differences among workers in this group. For example, 87 percent of doctors working in hospitals were vaccinated. But in nursing homes, other than doctors and nurses, the vaccine coverage rate was 50 percent. “This is worrisome because these people care for people at high risk for complications from flu,” he said.

Getting vaccinated is the best protection from the flu, Koh said. Everyone 6 months and older should get a flu shot every year. Last season’s vaccination campaign prevented almost 5 million cases of the flu, 2 million doctor’s visits and 40,000 hospitalizations, according to CDC estimates.

More information

To learn more about the flu, visit the U.S. Centers for Disease Control and Prevention.

SOURCES: Sept. 27, 2012, news conference with Howard K. Koh, M.D., M.P.H., assistant secretary for health, U.S. Department of Health and Human Services; Daniel Jernigan, M.D., M.P.H., deputy director, Influenza Division, U.S. Centers for Disease Control and Prevention

Get Adobe Flash playerPlugin by wpburn.com wordpress themes