Recording and written materials of AIS's audioconference on July 9, 2008

Next-Generation Specialty Pharmacy Management Strategies for Health Plans

Estimates show that specialty pharmacy costs will almost double over the next few years, with a whopping $100 billion expected to be spent on these drugs by the end of this decade. While companies continue to produce promising therapies, these drugs can cost hundreds of thousands of dollars annually — for just one patient. Health plans must go beyond merely shifting these drugs onto a fourth tier and instead arm themselves with a variety of new specialty drug management strategies such as pay for performance and innovative manufacturer contracting to combat the wave of specialty pharmaceuticals coming down the pike. Find out what novel strategies insurers are using and should use to manage specialty drugs.

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With health plans spending an increasingly larger amount on specialty drugs — almost $60 billion last year — these products now are front and center on insurers’ radar screens. One patient alone could easily incur annual therapy costs of $300,000 or more.

But many plans’ management approaches consist of little more than simply dumping the drugs into the fourth tier of the non-specialty drug formulary. While traditional tiering has worked well for managing non-specialty drugs, specialty drugs have various qualities that make them inappropriate for this kind of approach.

Advances in medicine are coming fast and furious, with many targeted therapies hitting the marketplace. And while specialty drugs have traditionally treated smaller patient populations, some high-cost therapies are in clinical trials for more widespread conditions, such as asthma. Plans need to bear down and rapidly develop new management approaches to specialty drugs, such as outcomes-based contracting, that can produce efficiencies in both payer costs and patient health.

• How will payers utilize companion diagnostics to produce efficiencies in the growing area of personalized medicine?
• How can payers apply pay-for-performance strategies to specialty drugs?
• How can outcomes-based manufacturer contracting be applied to specialty pharmacy management?
• How can plans design their benefits to properly manage specialty pharmaceuticals?

 

DEBBIE STERN, R.Ph., is vice president of Rxperts, a managed care consulting firm in Irvine, Calif., where she is responsible for designing and implementing comprehensive programs to meet the needs of managed care clients. She has recently devoted considerable time to projects related to specialty pharmacy for all segments of the health care industry. In addition to 12 years of managed care experience, Ms. Stern spent five years in the pharmaceutical industry and 10 years in retail pharmacy. She has a B.S. in pharmacy from the University of Cincinnati and is actively involved in the Academy of Managed Care Pharmacy, where she recently completed a two-year term on the board of directors.

EDMUND PEZALLA, M.D., is national medical director at Aetna Pharmacy Management. He joined Aetna in August 2007 as national medical director for pharmacy management. Dr. Pezalla has worked with several health care organizations in administration, disease management and pharmacy benefits including Prescription Solutions, a unit of UnitedHealth Group. He is a graduate of Georgetown University (B.S. and M.D.), and received his master of public health from the University of California at Berkeley. He is a board-certified pediatrician, having trained at the Bethesda Naval Hospital. Dr. Pezalla has also completed a fellowship in health services research and the coursework for the doctoral degree in health services organization and policy at the University of Michigan.
 
Moderator: Angela Maas, managing editor of AIS’s Specialty Pharmacy News.

Strategic planners; product development, contracting and marketing executives; pharmacy, clinical services and medical directors; and financial and operations executives at