How PBMs Can Help Control the Cost of Specialty Medications


PBMs can implement a clinically rigorous approach to specialty pharmacy management that ensures members have appropriate access while helping payers control their pharmacy spend.

Specialty medications are making headlines for a reason: they’re a major and growing driver of health costs. As the nation’s largest pharmacy benefit manager (PBM), we see the impact that these treatments have on pharmacy spend first-hand. In 2020, 52% of pharmacy spend for our clients was driven by a tiny fraction—just 2.5%--of members who use specialty medications. So, it’s no surprise that they are a major area of concern for payers and employers looking to control plan costs while providing sustainable health benefits.

Recently, the author of an article published in Pharmacy Times in looking at the many challenges involved with the cost specialty medications, posed the question whether PBMs can help manage the high costs associated with these treatments. The answer, of course, is that PBMs can—and do—make it possible to implement a clinically rigorous approach to specialty pharmacy management that ensures members have appropriate access while helping payers control their pharmacy spend.

PBMs such as CVS Caremark are especially well-suited to this task because of investments in a strong digital infrastructure and interoperability that enables the use of advanced analytics to better manage utilization, eliminate waste, and support members throughout their treatment.

The Right Therapy at the Right Time

Our data show that 11% of all specialty medication spending occurs when a member first starts on a new therapy. Therefore, any effective management strategy needs to ensure costs are being managed right from the beginning by helping members quickly start on the most clinically appropriate therapy.

Using electronic health records (EHRs) to streamline the treatment selection and approval process based on diagnosis and clinical evidence can improve the member experience and lower costs by ensuring the most appropriate, cost-effective medications are being prescribed. For instance, at CVS Caremark, we can see the EHRs for approximately 70% of our specialty patients and approximately 30% of specialty prior authorization requests are submitted with information from relevant EHRs.

Eliminating Waste During Therapy

A vast majority—89%—of specialty medication spend occurs during ongoing therapy for existing users. This means managing specialty costs must be an ongoing process that extends throughout therapy. Members must be supported over the long term to effectively eliminate waste, control costs, and improve their health outcomes.

Many specialty medications can cause significant adverse effects (AEs). Often, the first treatment selected doesn’t work as intended. If a treatment is no longer effective, it can lead to an exacerbation of symptoms. Additionally, a member may experience serious AEs or a particular treatment may not be efficacious and, therefore, lead to an emergency department visit or hospitalization. Any of these instances are not only traumatic for the member, but can also cause the cost of their care to jump. If the member falls off therapy, this results in further wasted spend.

PBMs can use advanced analytics to monitor for gaps in care, treatment efficacy, worsening of symptoms, and risk of AEs. They can also engage members and coordinate with providers when appropriate. Our analysis of our own prescription claims found that ongoing therapy-specific assessments and targeted interventions led to 23% of patients stopping a therapy or changing to another medication in the first 90 days, helping save nearly $2000 per targeted patient.

Another way to control costs is simply to help members avoid inadvertent hoarding of medications. Given the high price tags associated with specialty medications, even small overages and excess supply accumulations could add up to significant wasted spending.

Advanced analytics can help us understand individual prescription refill patterns and monitor for accumulation of excess medication supply. We can then engage members via the method they prefer, working to adjust fill dates and make sure they have the medications they need but without the wasted spend on additional, unused doses. Such supply optimization alone can save up to $2600 per targeted patient.

Supporting Members and Through Care and Treatment Management

Last but not least, PBMs can offer specially trained care teams—pharmacists, nurses and other clinicians—can help support and engage members for better condition management, improved outcomes, and lower overall cost of care. For instance, our analysis shows that support from AccordantCare’s skilled nurses can help reduce hospital admissions among specialty patients by 11%, which resulted in more than $2100 in savings per year per engaged member.

This is because these trained, experienced teams can not only counsel members, but also intervene when needed if a member is having challenges adhering to treatments or managing AEs. This can help prevent AEs or a worsening of their condition. Increasingly this can be done from members’ own home—over the phone, online, and even via secure messaging and mobile apps.

Managing the high costs of specialty medications can be as complex as the conditions they treat. PBMs have the insight and ability to ensure that people with complex care needs get the most clinically appropriate, cost-effective treatment and ongoing support while eliminating waste to deliver lasting cost savings. This makes PBMs an indispensable ally in the fight against rising specialty costs.

About the Author

Prem Shah, PharmD, Executive Vice President of Specialty and Product Innovation, CVS Health.

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