Krishna Rutvij Patel

The problem is not how to decrease specialty pharmacy cost; that will never happen. Rather, it is how to reduce the rate of increase in specialty pharmacy cost. Payers face a market characterized by a growing number of specialty drugs with high price tags. Specifically, Express Scripts’ Drug Trend Report predicts that hepatitis C drug spending will quadruple from 2013 to 2015 — just two years — the greatest percentage increase of all therapeutic areas. Gilead’s Sovaldi is the most recent drug approved for hepatitis C and is, rest assured, the first of several pipeline hepatitis C drugs from AbbVie, Bristol-Myers Squibb, and Achillion that will contribute to this upward trend. Let’s take a closer look at Sovaldi from the formulary decision-maker perspective.

Formulary decision-maker concern How these concerns can be addressed
Sovaldi costs about $84,000 per 12-week course. This may be unsustainable. Although the drug cost may be high, it might be offset by avoiding side effects and hospitalizations that may be associated with cheaper competitors. Gilead made such a case at the 2013 International Liver Conference, presenting data on real-world costs of competitors. This is especially relevant inasmuch as hepatitis C is the leading cause of liver transplants. Furthermore, consider oncology drugs whose prices may be just as high but often do not have cure rates as high as Sovaldi’s.
Payers may feel compelled to provide unrestricted access to Sovaldi because of its potential to increase adherence because it is a once-daily oral drug that avoids the side effects associated with other drugs. Sovaldi’s cheaper competitors may be perceived as an obstacle to adherence because of their safety profiles and the fact that they are injectables. Adherence may be boosted by effective specialty pharmacy programs.
Diagnoses of hepatitis C will increase because of new screening guidelines. Therefore, the total cost of treating hepatitis C will increase. Newer diagnostic tools that are also less invasive, such as FibroScan, may allow payers to tightly manage access to Sovaldi by requiring routine screening before coverage is approved.
Gilead has refused the Fair Pricing Coalition’s demand for lower pricing of Sovaldi, although it has agreed to yield to the FPC’s requests regarding Sovaldi access programs, such as SupportPath, which help patients in need of financial assistance. Express Scripts, one of the largest PBMs, threatens to block Sovaldi from coverage altogether if its pipeline competitors will accept lower pricing.

Cost increase of hepatitis C treatment will far exceed specialty drugs in general

Sources: HCV Research and News, GlobalData, CVS Caremark Insights, AIS, Bloomberg, Express Scripts

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.