Healthcare Industry Transformation to Meet Employer Demand for Managing Specialty Pharmacy Costs

According to Howard K. Crowley, head of pharmacy strategic initiatives, Aetna Pharmacy Management, a Towers Watson/ National Business Group on Health survey found that 29% of employers rank the rising costs of specialty drugs as a top challenge to keeping health benefit coverage affordable.

He says that while most prescriptions will be written for generic prescription drugs, most of the costs will be for specialty medication. In 2013 drug spending totaled $35 billion, but by 2021 is could be as high as $160 billion. He added that 77% of drug spend is associated with 6 therapeutic categories and 40% of drugs filed for FDA approval are specialty. Of course, specialty pharmacy costs are only part of the problem. Other challenges include the 90,000 projected shortfall of physicians by 2020, and the 46,000 projected shortfall of specialists by 2020.

There are a wide variety of specialty therapies for different conditions including multiple sclerosis (MS), hepatitis C, and in oncology. MS, for instance impacts an estimated 400,000 people in the United States, with about 10 drug treatment options. Hepatitis C has a prevalence of 3.2 million, more than 6 disease variations, and 7 drug treatment options.

Mr Crowley says that successful solutions must consider all the challenges, especially in areas such as treating MS, hepatitis C, and oncology. He argues that leaders in specialty pharmacy services require decisions supported by:

• Comprehensive clinical evidence and polices for therapy
• Affordable options for delivery of care
• A knowledgeable support system that covers all patient needs

Pharmacy analytics should consider the drug choice, site of care, and support systems available. For example, a focus on oncology might include looking at the drug choice (ie, diagnosis validation, dose and frequency edits), the site of care (ie, oncology patient centered medical homes or tiered networks), and support (ie, case management or behavioral health).

Mr Crowley says that Aetna recognizes the changes required in traditional operating models that will allow the industry to meet the demands of employers. Collaboration can result in better outcomes, especially when medications are administered in a clinically appropriate setting at a rational price, and there are networks to support evidence-based medicine treatment pathways. As well, a wide array of benefit tools can ensure clinically appropriate therapy. Finally, patient, provider, and caregiver support systems should be designed to be efficient and deliver the best health outcomes.

“We need to take a broader look,” Mr Crowley says. “[Payers] working collaboratively with providers—that’s the future.”