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Oncology
Drug Management: A White Paper on Marketplace Challenges, Opportunities
and Strategies
by
Chris Nee, Pharm.D., M.B.A., President, PharMedQuest
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of Contents
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Pages: 72
PDF Version: 907 KB
ISBN: 1-933801-18-2
© 2007
Pub Code: BODM-E551E
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Unlike
traditional prescription drug management programs, oncology drug management
has proven to be very different in terms of aligning stakeholders'
incentives and identifying inefficiencies in the system. Oncology
Drug Management: A White Paper on Marketplace Challenges, Opportunities
and Strategies is packed with information that will help you
navigate this increasingly complex landscape.
Written
by widely recognized pharmacy benefit expert Chris Nee, and filled
with data and illustrations that clearly explain this evolving industry's
history and current climate, this 70-page white paper is an indispensable
resource that includes:
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A
thorough history of health plan payment and reimbursement, focusing
on the challenges payers face in current payment schemes.
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Case
studies of various reimbursement scenarios, highlighting the opportunities
for all types of vendors along the drug distribution chain.
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Practical
advice — with examples — on how to design a cost-effective
oncology drug program for your organization.
As
oncology drug costs to payers continue to soar — almost $200
billion annually and growing — new technologies and market forces
are combining to allow health plans to aggressively manage oncology
drug costs. Oncology Drug Management: A White Paper on Marketplace
Challenges, Opportunities and Strategies will show you what
steps to take to manage the costs of chemotherapy and related drugs.
Table
of Contents
Background
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Cancer
and its Impact on the U.S. Population
Graph 1. Expanding Age Population
Graph 2. U.S. Death Rate, by Heart Disease vs. Neoplasms, From 1975
to 2001
Table 1. Top 15 Brand Name Drugs by Total Revenue in the U.S. for
2005
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Chemotherapeutic
Drug Research and Development Pipeline
Graph 3. Biotechnology vs. Conventional Drug Approval Rates in
the U.S.
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Cost
Burden of Cancer Treatments
Graph 4. Pipeline of Biotechnology Drugs by Disease Type
Table 2. Top 10 Specialty Drug Therapeutic Classes in Caremark's
2005 Book of Business
Payer
Landscape: Adaptation of Biotech-Chemo Agents
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Table
3. Service and Reimbursement Categories per CMS' Medicare Program
Table 4. Sample J-Codes for Selected Drugs
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Payment
Process Under the J-Code System
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Inherent
Challenges to the J-Code Reimbursement Scheme
Table 5. Average Wholesale Prices of Commercially Available Medications
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Evolution
of the J-Code Reimbursement Pricing Scheme
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Buying
Part B Drugs Uniquely Favors Oncologists
Table 6. Drug Pricing According to Class-of-Trade Designation
Changing
the Landscape of Payer Reimbursement for
Chemotherapeutic Drugs
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History
and Impact of Chemotherapeutic Reimbursement
Graph 5. CMS Planned Reimbursement Changes Between 2003 and 2005
Table 7. Changes to CMS Drug Payment Methodology from 2004-2006
ASP Synopsis
CAP Synopsis
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Aligning
Incentives in Oncology Drug Reimbursement
Table 8: Reimbursement Rates Comparison
Table 9: Market Prices for Certain Oncology Drugs Are Below ASP
+6%
Medical
Benefit vs. Pharmacy Benefit for Chemotherapeutic
Drug Reimbursement
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Managed
Care Synopsis
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ASP
May Not Provide Cost Savings in the Long Term
Table 10. ASP Changes Between 4th Quarter 2006 and 1st Quarter
2007
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Oncology
Medications: Challenges Facing Payers/Health Plans
Case Study - JM
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Specialty
Pharmacies: Risks and Rewards Analyzed
Case Study - Author
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Specialty
Pharmacy and Class of Trade (COT)
Specialty Pharmacy Usage On the Rise
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Specialty
Pharmacies: AWP versus ASP
Case Study - CP Health Plan
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Payer
Challenges in Managed Care
Case Study - WFHC
Oncology
Medications: Challenges Facing Oncology Practices
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Case
Study - Dr. JL, Oncologist
Remembering the Good Old Days
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Case
Study - Higher Drug Margins Under Oncologist COT and Patient Copayments
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Oncologist
Class-of-Trade Synopsis
Table 11. Examples of Commercial Payer Default Fee Schedule Change
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Case
Study of the New CMS Professional Services Payment Schedule
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Drug
Replacement Through Specialty Pharmacy
Case Study - WFHC and Delays in Delivering Medications to Doctors
Opportunities
in the Oncology Drug Space
Strategy
for a Cost-Effective Oncology Drug Management
Program
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Optimize
Excess Capacity in the Marketplace
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Optimize
Leverage in Purchasing
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Design
the Proper Strategic Program
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Establish
Criteria for a Cost-Effective Oncology Drug Program
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Examples
of Programs that Align Incentives, Leading to Win-Win Scenarios
Summary
Glossary of Managed Healthcare-Related Terminology
Written
By
Chris
Nee, Pharm.D., M.B.A., President, PharMedQuest
Dr.
Nee is a widely recognized expert with more than 15 years of experience
in managed care pharmacy and pharmaceutical management, including
benefit design, PBM operations, sales and marketing, and clinical
program development. He has been a long-time contributor to AIS publications
and has authored several publications on pharmacy benefit management
topics. He received a doctorate of pharmacy from the University of
Michigan and an MBA from the University of California at Irvine.
PharMedQuest,
based in La Habra, California, is a leading pharmaceutical management
consulting firm serving health plans, PBMs, providers and manufacturers.
Written
For
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Health
plans
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Pharmacy
service providers, including:
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PBMs
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Home
infusion pharmacies
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Specialty
pharmacies
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Benefit
design consultants
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Disease
management firms
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Pharmaceutical
manufacturers
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Oncology
practices
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Specialty Pharmacy: Stakeholders, Strategies
and Markets
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