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Specialty prescription drugs accounted for almost one-quarter of the U.S. total drug costs within the pharmacy benefit last year-hitting an all-time high, even though fewer than 2% of the population is affected by diseases that require these medications, according to data released by Express Scripts on March 5.
In its recent publication, The Express Scripts 2012 Drug Trend Report, the costliest diseases in terms of prescription drug spend included inflammatory conditions (such as rheumatoid arthritis), multiple sclerosis, cancer, and HIV. Inflammatory conditions were the costliest specialty category, driven by a 9% increase in utilization and a 14% increase in unit cost, according to the report. Hepatitis C accounted for a 33.7% increase in drug spend, making it the largest rise in drug spend than another other major therapy class-specialty or traditional.
Traditional prescription drug spending declined for the first time in more than 20 years, with 1.5% decrease in 2012. This trend was attributed to increased utilization of lower-cost generics for the blockbuster medications that came off patent last year. Regarding Medicare specifically, research showed that physicians were more likely to prescribe generic drugs to these patients if physicians were younger, if they treat a large number of Medicare patients, or if they have practices located in the Midwest.
“The first-ever decrease in traditional drug spending is the latest chapter of an ongoing success story for our utilization management programs and for an increased interest in generic medications, home-delivery pharmacy, and more focused retail pharmacy networks,” said Glen Stettin, MD, Express Scripts senior vice president of Clinical, Research & New Solutions.
“These same principles of effective management solutions and increased drug competition are necessary to the country’s effort to rein in specialty drug costs,” said Dr. Stettin, in a prepared statement.
To control specialty drug costs, Express Scripts conducted a study to analyze the costs of these expensive medications among 60 employer clients, representing more than 5 million Americans with pharmacy benefits. Employers were placed into three groups based on the type of cost-containment programs that they employed.
The first group was the unmanaged category in which the health plan allowed employees to go to any pharmacy for their specialty medications and no specialty utilization management program was used. The second or somewhat managed group included a health plan using a specialty pharmacy exclusively and one specialty utilization management program. The third or tightly managed group included a health plan that used a specialty pharmacy exclusively and multiple specialty utilization management programs.
Express Scripts found that tightly managed employer health plans had half the annual increase in specialty drug spending per member per year (13.6%) than the unmanaged group (27.8%) and almost one-third the increase of the average annual projected specialty drug costs. The results of the study were released March 7 at the National Business Group on Health’s Business Health Agenda 2013 conference in Washington, D.C.
Express Scripts offers a new platform, Health Decision Science, from its subsidiaries CuraScript and Accredo specialty pharmacies, to provide cost-effective and clinically appropriate decisions for health plan members. The pharmacy benefit manager (PBM) also offers Specialty Benefit Services, including clinical specialization, clinically based formulary design, pharmacy-network and utilization-management solutions, and a medical benefit-management solution, according to a company statement.
“Express Scripts Specialty Benefit Services means enabling better decisions and healthier outcomes in specialty pharmacy through three complementary capabilities-behavioral sciences, clinical specialization, and actionable data,” said Mary Dorholt, PharmD, vice president and clinical practice lead of specialty for Express Scripts.
“These core capabilities are designed to deliver better adherence to medications, which are costly and can have serious side effects, decrease waste in areas of appropriate drug choice, dose, and length of therapy, as well as avoid potentially harmful drug interactions that could lead to adverse events and costly hospitalizations,” Dorholt told Drug Topics. “Our effective use of data helps us identify opportunities for improvements, but also measure outcomes and results.”
Dorholt explained that there is a need to manage specialty drugs that come under the medical benefit, as these drugs make up 47% of the total specialty drug spend. Some of these drugs can be migrated to the pharmacy benefit for dispensing where traditional pharmacy benefit management techniques can be employed, she said.
“In addition, Care Continuum, an Express Scripts company, offers comprehensive medical benefit management solutions to better control medically billed specialty drug spend, including associated drug administration services,” Dorholt said. “Our user-friendly provider portal, ExpressPAth, enables physicians to manage prior authorizations (PA) across both the pharmacy and the medical benefit, reducing administrative demands and seamlessly offering a single PA process across the healthcare spectrum.”
Express Scripts merged with Medco Health Solutions last year, making it the largest PBM in the industry, covering more than 100 million lives (40% of the market).
Catamaran, another PBM, also works with its clients to control specialty prescription drug costs. Through its specialty pharmacy, BriovaRx, Catamaran employs a hands-on and personalized approach to help these patients better manage their own healthcare, according to David Calabrese, RPh, MPH, Catamaran’s vice president and chief pharmacy officer.
“We want to provide a more active coordination of the patient’s care-not only with the patient but with the caregiver and the provider community,” Calabrese told Drug Topics. “We are monitoring these patients, and they are educated up front about the medications and have a good understanding of what to expect in terms of effectiveness and potential side effects. It may be necessary to reach back out to the health professional-whether it is one of our own pharmacists or nurses or their own clinician who prescribed the medication.”
Catamaran provides a risk-benefit evaluation for ongoing therapy with specialty medications. At times, the clinician may be advised to discontinue a medication if the benefits do not outweigh the side effects, Calabrese said.
“Specialty drugs represent one of the biggest challenges but also one of the biggest opportunities for an organization like ours and our clients,” he said.
Catamaran became the fourth largest PBM in the industry last year with the merger of SXC Health Solutions and Catalyst Health Solutions. The company covers 25 million lives or less than 4% of the market.