As the price tags for therapies coming to market have soared into the hundreds of thousands and even millions on occasion, paying for them has become an ever-greater cause of concern and focus area.
Specialty conditions—and often the therapies used to treat them—are complex. Getting diagnosed alone can be a source of anxiety. For people living with these conditions, successfully managing their symptoms while also dealing with complicated medications regimens and adverse effects (AEs) can be challenging.
The lifestyle changes often required for successful condition management can make the experience overwhelming. These medications are also usually very expensive, which is major area of concern for payers and patients alike.
In recent years, as the price tags for therapies coming to market have soared into the hundreds of thousands and even millions on occasion, paying for them has become an ever-greater cause of concern and focus area. As a result, we have seen a trend of payers looking for new ways to lower their specialty spend or even stop covering certain high-cost medications.
Some niche vendors are luring employers with promises of significant savings if they “carve-out” the specialty benefit from an integrated management approach by a pharmacy benefit manager (PBM). Recently, my colleague Prem Shah, PharmD, shared his perspective on why such approaches fail to deliver true, lasting savings and may carry hidden risks or costs.
Truth is, such approaches are also ineffective—and even risky—from a clinical and patient safety perspective.
The Problem with Aggressive Denials
Pharmacy benefit management is fundamentally a balancing act. We need to ensure that patients who need specialty treatments to manage their conditions can access therapy in a timely manner.
Undue delays in therapy can jeopardize a patient’s health. At the same time, we need to ensure that we minimize unnecessary use of medications that are not clinically appropriate.
To do this, PBMs use clinical best practice guidelines from professional organizations and up-to-date clinical research. Carve-outs promise cost savings through aggressive criteria and utilization management based on some modest evidence base but may not meet standard of care.
The implications of not using standard of care criteria are that there may be initial denials. However, 1) patients may not be receiving standard of care, which is problematic from a clinical quality and outcomes standpoint and 2) the denial may not be upheld upon appeal.
Lack of Patient Support and Engagement
Once a patient starts treatment with an appropriate therapy, there are many strategies to ensure that they continue it, and at the right dosage and frequency, to manage their health. When considering which kind of specialty management to adopt, it is important to know whether the vendor offers care management support for patients and members.
Are the vendor’s processes helping ensure that patients are starting on the right medication as quickly as possible? Once they are on it, are they receiving the support they need to stay on track? Is their approach accredited by independent third-party organizations, indicative of their commitment to high quality standards, patient safety, and access?
Depending on the condition, patients not only struggle with adherence, but may also require screenings, testing, and monitoring of specific factors such as blood pressure, symptoms, and any potential AEs. Many of those with complex conditions may also need mental health support or help addressing social determinants of health and disparities.
A Clear Choice
An integrated approach that aligns to the latest clinical treatment guidelines and in which decisions are evidence-based and dependent on the individual’s specific diagnosis and other information is necessary for both better outcomes and effective cost control. It enables care management services offered by a specialty pharmacy to be incorporated into the PBM offerings to ensure appropriate utilization management as well as the support patients need to manage their care journey.
Nurse-led care management is a longitudinal and holistic approach based on understanding the underlying dynamics. It considers the person and their circumstances as a whole for intervention by a team of specialized practitioners. It can address acute care needs while focusing on evolving issues to prevent avoidable adverse clinical and utilization outcomes proactively.
Care management also means advocating for the patient with the aim of promoting better quality of life, improving care coordination, meeting the patient’s needs, helping them achieve their health goals, being aware of social determinants of health, and lowering overall costs for payers and members.
A care management team helps the patient navigate managing a complex condition for immediate needs and over the long term. When a care management program is also accredited by independent, third-party organizations, it demonstrates that its design meets and/or exceeds all of the required characteristics to address individual member needs, and an ongoing commitment to quality and performance.
It is clear that this approach delivers results. For instance, among patients who received support through our accredited AccordantCare program, 98% reported having a better understanding of how to manage their condition. Support from AccordantCare Rare teams—focused on rare and highly complex conditions—also led to an 11% reduction in hospital admissions and more than $2100 in savings per engaged member per year.
And with the growth in digital tools and solutions, an integrated approach that also makes investments in technological infrastructure can make sure patients have the support they need whenever, wherever and however they choose.
The combined power of member engagement through digital tools, ongoing innovation, and the care provided by specially trained CareTeams can help members self-manage their conditions, improve clinical outcomes, and avoid downstream costs such as AEs and hospital visits.
About the Author
Sree Chaguturu, MD is Chief Medical Officer, CVS Caremark, where he focuses on enhancing the quality of services provided to millions of its members and patients, while also contributing to the overall mission of CVS Health. Most recently, he was Chief Population Health Officer at Partners HealthCare. In this role, he led the system’s accountable care organization, one of the largest in the nation serving over 600,000 lives. Previously, he was a health care consultant at McKinsey and Company. Dr. Chaguturu is a practicing internal medicine physician at Massachusetts General Hospital and a Lecturer at Harvard Medical School. His articles have appeared in publications such as the New England Journal of Medicine, JAMA, and Health Affairs. Dr. Chaguturu received his Bachelor’s degree in biology from Brown University and his doctorate of medicine degree from Brown University Medical School. He completed his internal medicine and primary care training at Massachusetts General Hospital.