Emerging Trends Affecting Market Access to Specialty Therapies

A new payer study from Avalere Health LLC and Janssen Biotech, Inc released at the 2013 Armada Specialty Pharmacy Summit seeks to determine which innovative strategies will be most successful in managing access to specialty drugs.

A new payer study from Avalere Health LLC and Janssen Biotech, Inc released at the 2013 Armada Specialty Pharmacy Summit seeks to determine which innovative strategies will be most successful in managing access to specialty drugs.

Although the picture of health care in a post accountable care organization (ACO) environment is still somewhat unclear, predicted cost pressures in specialty drug management are prompting health plans to “think outside the box” when it comes to ensuring appropriate access to expensive biologics in the future.

To respond to the enormous growth anticipated in specialty drug trend, payers need to be proactive regarding cost reduction. A record number of specialty drugs are in the pipeline, and now that specialty spend is outpacing growth in the traditional drug market, health plans are looking for new ways to allow their patients just the right amount of access to these drugs. This approach is also known in the industry as, “The right dose to the right patient at the right time.”

Many industry experts have asserted that the go-to, tried-and-true utilization management techniques of the past—such as prior authorization and step therapy—will not be sufficient to manage the ever-growing specialty spend. It seems that a new report on management of biologics is issued every day, but few reports highlight the emerging and innovative spend strategies that payers may have to implement to effectively manage their bottom lines.

The inaugural executive brief from Avalere Health, launched in collaboration with Janssen Biotech, Inc and Johnson & Johnson Health Care Systems, highlights the most promising future specialty spend activities and identifies the challenges involved in implementing each method.

Emerging activities are defined by the report as cost-reduction methods employed by some health plans that are not yet in widespread use.

The 90 stakeholders surveyed in the publication report that they are implementing a total of 800 activities to reduce specialty spend, with 45 different methods across 8 “opportunity areas,” including “both incremental changes to existing tools, as well as new models.” These are: delivery system changes, payment system changes, site-of-care optimization, clinical pathways, medication adherence, innovative contracting arrangements, benefit design and utilization management, and medical and pharmacy integration.

Of these 8 activities, the majority of health plans, including national, regional, and integrated delivery systems (IDSs), see 4 methods as “emerging”: payment system changes, delivery system changes, clinical pathways, and benefit management and utilization management. Of these, the 3 activities forecast to be most successful in specialty drug management are payer/provider contracts for centers of excellence, episode of care or bundled payments, and reauthorization to continue drug therapy.

In reference to implementation of these initiatives, the report notes that it is unclear whether the “regionalization” of health care will have an impact on the rate of change, or whether the launching of “paradigm-changing initiatives” such as risk-bearing ACOs will be more common than incremental initiatives such as split-fill programs for oral medications known to have potentially strong adverse effects.

Across all plans, stakeholders said that the barriers to successful implementation of innovative cost control tactics include plan budgetary constraints, difficulty measuring outcomes, and hurdles regarding organizational buy-in, particularly when it comes to provider acceptance, which was labeled as the “number one critical success factor for new initiatives” by all 3 health plan types. This may be compounded by the fact that, to date, only 65% of integrated delivery systems, 54% of national plans, and 36% of regional plans have entered into ACOs.

Leigh Ann Bruhn, MBA, director, Avalere Health, told Specialty Pharmacy Times that, of the report’s findings, she was most surprised about how the different plan types view the importance of ramping up their information technology (IT) efforts. While 95% of national plans and 93% IDSs are making IT infrastructure a priority, only 30% of regional plans report investment in IT programs. It is unknown whether this disparity is simply because regional plans have less capital, Bruhn said, or because their priorities lie elsewhere.

Finally, the report provided 4 examples of “compelling and innovative activities from the market.” The following tactics and companies were identified in case studies as examples of best practice:

  • Site-of-care strategies: Walgreens Co.
  • Disease-specific ACOs: Florida Blue, Baptist Health South Florida Health System, and Advanced Medical Specialties
  • Clinical pathways: CareFirst BlueCross BlueShield and Cardinal Health Specialty Solutions
  • Partial-fill programs: Humana RightSource Specialty Pharmacy