Specialty Drug Learning and Action Network: Member Highlights
All employer members of The Action Group are invited to participate in Care Delivery Learning Networks to help drive needed marketplace change in the areas of overuse, cost and medical intervention variability. Learning Network involvement provides a unique opportunity to take a deep dive on specific issues, to collaborate with peers, and to meet face-to-face with health plans, providers, vendors and thought leaders to develop Employer Purchaser’s Guides.
Following the release of the Specialty Pharmacy Purchaser’s Guide, Jon Born, senior director of benefits at UNFI, was asked to discuss his Learning Network experience. Karen Chapin, health programs manager at the University of Minnesota, was asked to talk about the University’s specialty pharmacy program, which is carved out from the pharmacy benefit manager (PBM), which is carved out from the health plan.
Highlights of Jon’s Remarks:
- On specialty pharmacy drug pricing:
- It quickly became clear that pricing is out of control in the U.S. Manufacturers are charging whatever the market will pay, regardless of cost to them.
- It’s disheartening to see that the U.S. prices are subsidizing the cost of specialty drug dispensing around the world.
- Eye-opening examples:
- In 2014, insulin prices jumped 30 percent over two months, simply because pharmaceutical companies have the ability to change pricing at will, with no rational reason for doing so.
- The original cost of Sovaldi was $34,000 per patient, but when Gilead purchased the drug, the price was reset at over $84,000 per patient, or $1,000 per pill.
- On the economy:
- Over 20 percent of the U.S. gross domestic product (GDP) is wrapped up in health care interests. We need to find ways to link arms with the other health 80 percent to influence health care purchasing practices.
- According to a recent Rand study, nearly 80 percent of new dollars in the economy are absorbed by health care expenses. If we do not reverse this trend, our entire economy is at risk.
- On adjudication:
- National drug codes (NDCs), J-codes, and Q-codes need to be refined to ensure that claims are processed in a consistent and simplified way.
- Drugs are covered under both the pharmacy and medical benefit, and the diversity of payment and dispensing options makes it hard for payers to get full visibility on specialty drug spending or to mange drug utilization effectively.
Highlights of Karen’s Remarks:
- About 28 percent of our total pharmacy claims from last year were due to specialty claims.
- The University has a completely pass-through pharmacy program, and a separate specialty program precludes a built-in conflict of interest between the PBM and the specialty pharmacy.
- The arrangement of having a specialty pharmacy program, carved out from our PBM, carved out from our health plan increases our working knowledge of specialty medications. We have quarterly clinical meetings with our PBM and quarterly account management meetings with both our PBM and our specialty pharmacy.
- Our separate specialty pharmacy program has a significant focus on medication and care management, and has been regularly increasing the number of conditions to include. They have nurses trained in these areas and we reach a group of employees who aren’t touched by our other health coaching programs.
- By combining the support we get from our PBM and specialty pharmacy, we are more prepared to deal with the onslaught of specialty medications before they hit the market. By way of example, with the new PCSK9 medication for familial hypercholesterolemia, we are set to go with prior authorization, and we’ve made initial decisions about which conditions we are going to cover.