Health Plan Providers Interested in Managing Specialty Costs, Report Finds


Employers are concerned with worker health behaviors and want to control spending on expensive specialty medications, according to a new survey released by Express Scripts.

Employers are concerned with worker health behaviors and want to control spending on expensive specialty medications, according to a new survey released by Express Scripts.

A recent survey conducted and released by Express Scripts revealed that there is a major gap between worker intended behavior and actual behavior when it comes to making health decisions. As a result, employers have a renewed interest in promoting wellness programs within their companies, according to the report.

The survey, entitled “9 Leading Trends in Rx Plan Management,” gathered data from 318 plan managers from corporations, nonprofit, labor, and public sector groups to determine trends in prescription benefit philosophy, identify ways to control prescription costs, discover plan sponsor priorities, and assess perceptions regarding wellness management within health plans.

Although the main focus of the report was on ways employers can activate healthy worker behaviors through wellness programs, a section of the study was devoted to perceptions about controlling overall drug cost as well as the specialty spend.

“Over 50% of specialty spend goes unnoticed under the medical benefit,” noted the report. “Many plans are unaware of how to place controls on medical specialty spend or have not devised a plan to control trend on medically adjudicated drugs.”

There is an urgency to address client specialty spending, as 36% of plan managers cited use and cost of specialty medications as their biggest concern. This percentage increased to 58% in larger plans with more than 25,000 members. The larger the plan, the greater the concern associated with spending on costly specialty drugs, according to report authors.

In order to handle health costs in the specialty category, the majority of health plans reported using cost control measures such as step therapy, utilization management, days’ supply rules, and preferred specialty pharmacies. Usage of these control measures is expected to increase, both in the specialty and traditional pharmacy settings.

The report noted that 78% of the largest plan sponsors have added preferred and step-therapy rules to their plans, whereas only 61% of the smallest plans have added these cost control measures. Eighty-seven percent of the large organizations employ utilization management programs, versus 52% of the smaller ones.

It is interesting to note that although 69% of plans surveyed currently use preferred and step-therapy rules, and 82% intend to use these methods in the next 2 years, only 3% believe these methods to be the most effective. This is one of the lowest rated methods in terms of effectiveness, despite the high number of respondents that say they plan to use this technique in the coming years. Utilization management was deemed the most effective cost containment strategy by respondents (20%), and 18% believe that the use of copay waivers to encourage the use of a preferred pharmacy is a more effective way of managing cost, even though only 6% of plans reported using this system.

Biosimilar member incentives, medical benefit management, and moving specialty medications from the medical benefit to the pharmacy benefit were considered the least effective cost containment strategies by plan sponsors among all of the clinical programs mentioned in the survey.

More than 75% of plan sponsors say that behavior-driven conditions are the greatest contributors to high health care costs. The report authors note they expect to see increases in the usage of value-based plan designs and integrated pharmacy/medical data programs to promote plan member wellness in the future.

“A vast majority of our clients are now focusing on improving the health behaviors of plan members,” Tim Wentworth, senior vice president and president, sales and account management, Express Scripts, said in a statement. “This is critical, especially at a time when rising healthcare costs, waste from medication nonadherence, and suboptimal health outcomes are making it harder to provide a robust pharmacy benefit.”

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