Health plans continue cost-control measures, but have mixed reactions to specialty pharmacy services

The annual EMD Serono Specialty Digest, now in its 10th edition, is that manufacturer’s effort to survey trends among commercial and public health plans on how they are handling the administration of specialty drugs. Much of the discussion is the interaction between the plans and healthcare providers; the insights for manufacturers arise from the interplay of plans’ goals and how providers are meeting them.

The Digest tracks trends that have been progressing for some time: more specialty drugs are being handled as a pharmacy benefit and not a medical benefit (thus putting the drug cost out for review and monitoring); and formulary plans are being focused more closely on clinical outcomes. (Specific to oncology, 51% of plans have already, or plan to incorporate within the next 12 months, “clinical pathways” to standardize therapy. Also: 46% of plans include financial incentives to use generics and lower-cost drugs.) In what appears to be a brute-force approach to managing drug costs, 74% of formulary plans are composed with “preferred products regardless of mechanisms of action (MOAs)”—which implies that patient preference (or genetics) are of lesser significance. The other 24% “select at least one product from each MOA.” There are signs this might be changing: Currently, 14% of plans use an external vendor to manage companion diagnostics services, and that is projected to jump to 40% within the coming year.

A key question for pharma’s managed-care marketers is how pharmacy and therapeutics (P&T) committees make formulary decisions. According to the survey, nearly everyone (97%) wants to see head-to-head studies of comparable drugs. Three other highly ranked categories are conventional, randomized clinical trials; comparative effectiveness studies; and real-world evidence. Less-valued criteria are health economic data, retrospective data analysis, and non-randomized studies.

Some valuable tidbits from the survey:

• Currently, 19% of plans restrict use of coupons; this is expected to jump to 34% in the coming year
• Maintaining adherence to therapy is an important service provided to 68% of plans by specialty pharmacies, but only 60% of plans consider them “highly effective.”
• Fewer than half of plans indicate that they are satisfied with a range of specialty pharmacy services, including tracking outcomes (36% satisfaction); tracking discontinuations (32%); or documenting cost savings (46%)
• 42% of plans have instituted a “partial fill” program—which usually involves providing for a two-week rather than 30-day supply of a drug, to see how well it is accepted by patients and their conditions.

The full survey, which was introduced this week at the Academy of Managed Care Pharmacy conference (Tampa), is available at EMD Serono’s website.