This commentary proposes a research agenda that could inform policymaking based on a broader understanding the economic and social costs and benefits of specialty pharmaceuticals.
Am J Pharm Benefits. 2016;8(3):103-105
Specialty pharmaceuticals are medications that treat complex and serious or life-threatening conditions. Examples of such conditions include multiple sclerosis, hepatitis C, cancer, rheumatoid arthritis, inflammatory bowel disease, human immunodeficiency virus (HIV)/AIDS, and pulmonary hypertension. Specialty pharmaceuticals have relatively high costs per unit, often require special handling, and involve intensive ongoing clinical assessment.1-5
Specialty pharmaceuticals currently comprise the fastest-growing sector of the pharmacy market.6,7 In many cases, they represent the most effective—and sometimes the only—option for treating or curing serious or life-threatening diseases. Their therapeutic values notwithstanding, specialty pharmaceuticals recently have garnered attention for their costs, which can exceed $100,000 a year for some treatments.3
According to a 2014 Kaiser Family Foundation report, the percentage of employer-sponsored benefit plans with specialty pharmacy tiers—in which patients’ copayment and coinsurance costs are higher than for other medications—grew from 14% in 2012 to 20% in 2014.2 The average copayment for specialty medications was $83, compared with $31 for preferred brand name drugs with no generic substitute. Average coinsurance rates were 29% and 24%, respectively.2
The cost of specialty pharmaceuticals raises concerns that patients will find effective treatments unaffordable, especially if they are enrolled in high-deductible healthcare plans or plans that do not have out-of-pocket maximums.8 Some argue that the “savings” from foregone treatments may be illusory if untreated conditions contribute to the use of other high-cost treatments—for example, liver transplants in the case of untreated hepatitis C.
The lost productivity implications of serious or life-threatening conditions are absent from most discussions of specialty pharmaceuticals’ value. For example, statistics are vague on how many people do not participate in the labor force because of a serious illness, but could perhaps participate with the help of specialty treatments. Household earnings, payroll tax receipts, and the use of public safety-net programs, such as Medicaid and Social Security Disability Insurance, are all affected by such lost productivity.
Additionally, the incidence, wage replacement, and lost-productivity costs of sick-day and disability leaves due to untreated serious illness have not been considered fully. Therefore, decisions made about the cost-effectiveness of specific specialty pharmaceuticals likely have occurred without a full accounting of their benefits to patients, their employers, and society at large.
What is the evidence for workforce productivity?
There is reason to expect that effective treatments could have a positive productivity impact. Studies show that several conditions targeted by specialty medications are costly in terms of work outcomes, such as labor force participation, illness absence, disability leave,9 and job performance. These conditions include hepatitis C,10 rheumatoid arthritis,11 multiple sclerosis,12 a variety of cancers,13 and HIV/AIDS.14 Medications that help restore functioning for patients with such conditions would therefore have a value that is not captured by treatment costs.
What are the evidence gaps?
While medication adherence has been linked to better work outcomes for several chronic health conditions,15 few studies have examined the productivity impact of specialty pharmaceuticals. With the exception of rheumatoid arthritis11,16 and hemophilia,17,18 evidence describing patients’ work experiences before and after treatment with specialty pharmaceuticals is lacking. Few basic studies exist that describe symptomatic work limitations (such as fatigue among multiple sclerosis patients) that are not easily addressed by return-to-work or stay-at-work accommodations.
For specific conditions targeted by specialty pharmaceuticals, basic health and productivity research questions that remain unanswered include:
Advanced research questions could include:
What kind of research could close the evidence gaps?
Several research approaches could close knowledge gaps about the productivity impact of specialty pharmaceuticals. These include:
Existing studies show that several chronic health conditions targeted by specialty pharmaceuticals impact patients’ abilities to participate fully in the labor force. Treatments that help patients manage debilitating illness symptoms therefore may have economic and social benefits that offset some of their prescription costs.
However, empirical evidence to establish the economic and social value that specialty pharmaceuticals might provide among different groups of patients is limited by a lack of focused research. It is unclear how effective treatments might facilitate return-to-work or stay-at-work accommodations, or promote labor force participation more generally.
Given these knowledge gaps, a broad, intensive research agenda including both, quantitative and qualitative methods, is recommended. The questions and research approaches described in this commentary are not comprehensive. Nonetheless, they provide a foundation for a feasible research agenda on the overall costs and benefits of specialty pharmaceuticals. Cumulatively, the findings could provide stakeholders such as employers, policymakers, and patients’ groups with empirical evidence on which to formulate specialty pharmaceutical policies.
Author Affiliation: Integrated Benefits Institute (BG), San Francisco, CA.
Source of Funding: The article was funded from the general research budget of the Integrated Benefits Institute.
Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: The author is Director of Research and Measurement at the Integrated Benefits Institute, a 501(c)(6) non-profit membership organization focused on workforce health and productivity.
Address correspondence to: Brian Gifford, PhD, Integrated Benefits Institute, 595 Market Street, Suite 810, San Francisco, CA 94105. E-mail: email@example.com.
1. Academy of Managed Care Pharmacy Foundation. Specialty pharmacy and patient care: are we at a tipping point? http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=18858. Published October 7, 2014. Accessed April 29, 2016.
2. Kaiser Family Foundation. Employer health benefits survey, 2014 annual survey. http://kff.org/health-costs/report/2014-employer-health-benefits-survey/. Published September 10, 2014. Accessed April 29, 2016.
3. Health Affairs and the Robert Wood Johnson Foundation. Health policy brief: specialty pharmaceuticals. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_103.pdf. Published November 25, 2013. Accessed April 29, 2016.
4. Midwest Business Group on Health. National Employer Initiative on Specialty Pharmacy. http://www.specialtyrxtoolkit.com/. Accessed May 10, 2016.
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6. CVS Caremark. Insights: 7 sure things to help you know where to go next with your prescription benefit. https://cvshealth.com/sites/default/files/2014InsightsReport_ResearchArticle_PDF.pdf. Published 2014. Accessed April 29, 2016.
7. Express Scripts Lab. 2014 drug trend report. ExpressScripts_DrugTrendReport.pdf. Published March 2015. Accessed April 29, 2016.
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