Care Management Vital in Tackling Specialty Pharmacy Costs

Look for integrated care coordination when contracting with specialty drug pharmacies

By Greg Goth Feb 9, 2017
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Managing specialty drug benefits is becoming an increasingly critical, and increasingly frustrating, task for HR managers.

While the number of employees and their dependents who may need high-cost specialty drugs—typically for diseases such as multiple sclerosis, rheumatoid arthritis, hepatitis C and cancer—is usually very small, the percentage of total drug spending on these types of medications is disproportionately driving overall pharmacy and medical spending higher.

"Typically, 2 to 3 percent of prescriptions are specialty prescriptions, but they approach 35 to 45 percent of the overall cost" of a health plan's drug expenses, said Brent Eberle, general manager of Madison, Wis.-based Lumicera Health Services, a specialty pharmacy.

Pharmacy benefit management (PBM) firms, working on behalf of health insurers and self-insured employers, contract with retail and mail-order pharmacies for the "regular" drugs a plan covers (although some of the larger pharmacy chains are themselves PBMs). PBMs also may deal with specialty drug-exclusive pharmacies that interact with patients nationwide by e-mail and phone or may even create their own subsidiary specialty pharmacy.

For instance, Lumicera, established in 2014 by Navitus, a PBM, will fill about 70,000 prescriptions this year and provide disease-specific care management.

Stephen Schondelmeyer, a professor and head of the department of pharmaceutical care and health systems at the University of Minnesota College of Pharmacy in Minneapolis, said HR managers should make sure that any specialty pharmacy that their plan is using provides care management services for patients. These services are "becoming the norm for most of the conditions that end up being treated on the specialty list," he remarked.

Additionally, patient education should ensure that those taking specialty medications understand any special handling requirements associated with these drugs—some of which must be kept refrigerated, for instance, he noted.

When working with a specialty drug vendor, "that additional hands-on approach is absolutely critical," Eberle agreed.

According to the nonprofit Institute of Medicine, which is part of the U.S. National Academy of Sciences in Washington, D.C., up to 30 percent of prescriptions are never filled, up to 50 percent of medications are not taken as prescribed, and 10 percent of hospitalizations can be ascribed to poor adherence with medications.

Cheryl Larson, vice president of the Chicago-based Midwest Business Group on Health (MBGH), an employers association, said such statistics emphasize why specialty pharmacists need to offer comprehensive care to patients—and to show plan sponsors that they are doing so.

"Employers really do care about their employees and family members," she said. "They want them to be healthy and productive and have good quality of life, and if they are not doing well, employers need to know that."

[SHRM members-only toolkit: Managing Health Care Costs]

Knowledge Needs to Catch Up

While 63 percent of employers surveyed in 2016 by the MBGH said specialty pharmacy management was a top priority, a similar survey by the National Business Group on Health in Washington, D.C., indicated that only 35 percent of employers actually planned to implement "high-touch" case management for specialty drug patients.

"My impression is the general knowledge of how to deal with specialty drug coverage is still lagging, and often the busy HR manager will look to the easy solution and just let the PBM manage it," Schondelmeyer said.

Schondelmeyer's top recommendations for best practices when working with PBMs and specialty pharmacies include the following:

  • Don't use the same PBM you contract with for regular drug coverage. "You have to have separate entities" for specialty and nonspecialty drugs, he said. "The PBMs like to say, 'Let us do it for you,' but if you contract with [the same PBM for specialty drug coverage], there is no independent accountability for the specialty drug benefit."

  • Have the specialty pharmacy that's servicing patients define its care coordination process. How many rings does it take to talk to a person on the care coordination line? How often are they in touch with the patient? Schondelmeyer recommends that care managers initiate contact with patients about their therapy when a prescription is filled, following up one week later to check for compliance with the drug regimen, then one month later, and thereafter every three months.

  • Ask about the credentials of care coordinators. "The people doing the care coordination and talking to the patients may be either a pharmacist or a nurse, but there should be a pharmacy specialist for each treated disease as a backup," Schondelmeyer said.

Eberle recommends that HR managers evaluate how differentiated clinical care coordination is when dealing with different modes of drug administration, such as starting a regimen with an injectable drug.

"When going to a self-administered injectable, there is a whole new level of training and general education needed," he said. "Everyone's used to taking a pill, but when you have to actually do an injection, that can be very scary. So, education and reassurance on technique, and advice on how to handle disposal of needles, is also important."

A specialty pharmacy also should be tracking patient satisfaction scores and providing detailed answers to questions, including information on accreditation, Eberle noted.

A "nice to have" that should become increasingly common is tighter electronic medical record integration between the specialty pharmacy clinicians and the patient's primary care and health care specialists, Eberle said. Currently, "much of that information is still being done via fax, then entered into the electronic health record."

The Minnesota Health Action Group, a consortium of employers and government purchasers, posted a recent presentation outlining what HR managers should look for to derive top value from a specialty pharmacy. To illustrate its point that drug prices must be managed, an accompanying post from the group showed that in 2013 specialty drugs for just one condition—multiple sclerosis—would have caused costs to increase at one large Minnesota employer (with 40,093 covered health plan members) by $51.88 per member per year, or $2.08 million per year, if just 40 employees or dependents suffered from MS.

Greg Goth is a freelance health and technology writer based in Oakville, Conn.

Related SHRM Articles:

Employers Take Steps to Curb Specialty Drug Costs, SHRM Online Benefits, February 2017

Negotiating Price Transparency with PBMs Pays Off, SHRM Online Benefits, January 2017

Employers Prepare for 2017 Drug Price Hikes, SHRM Online Benefits, October 2016 

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