Supporting Cross-Benefit Management of Infused Drugs - Episode 7
Insights on findings from a study looking at the total cost of care of an infused multiple sclerosis drug, ocrelizumab.
Neil B. Minkoff, MD: Eric, you’re a chief pharmacy officer, right? Do you find challenges in trying to compare and contrast patient experience? That includes everything: direct cost, downstream cost, indirect cost, etc, on pharmacy drugs vs. medical benefit drugs. How do you address those challenges?
Eric Cannon, PharmD, FAMCP: That member experience is a critical thing. Any 1 of us who has had to enter into the health care system at some point in time has realized how complicated it is. That’s something that, if I look at the approach we’ve taken recently, especially around MS [multiple sclerosis], it is looking with the neurology department that exists within our organization and how we streamline that patient experience. What I don’t want is for the patient to go into a physician’s office and the physician to say, “The best drug for you is this infusion.” They infuse it, and they didn’t get a prior authorization. We deny it back to the provider, the provider tries to balance bill, we get involved and have an argument with the provider, and it goes back and forth.
In the meantime, there’s a patient with MS stuck in the middle of it, and they didn’t go to see the doctor because they were feeling great. They didn’t go to see the doctor because their MS wasn’t where it should be. They went to see the doctor because they felt crappy, and they got an exacerbation of their MS. The last thing they need is a health plan and a provider sitting on either side of them arguing about it. That’s what we’ve looked at to say that the experience a patient has is as critical as not only the drug we select, the amount they pay for their premium, or what their co-pay may be. It’s also about how we optimize that experience, how we make it seamless, and how we help them navigate through this. We’re far from there.
Don’t get me wrong when I say that I think we’ve nailed it, because I don’t think we’re even close to it. That needs to be a focus of ours as we go forward and as we work with providers to make sure that providers know the drugs that require prior authorization. Within the neurology came the neurology department. Neurology leadership needs to be involved. Throughout all this, as we look at the organizations where we work, that engagement of leadership is critical. You’ve got to bring them in. If I’m working directly with the neurologist, and the chief of neurology is telling that neurologist that they need to infuse more or do something different, then we just counteract each other. It is important to have leadership buy-in and to work together so that not only does the neurologist know, but their MA [medical assistant] and their physician assistant or whomever they work with in the office, can pull in that appropriate information and say, “Wait, we’ve got to stop and get a prior authorization on this.” That comprehensive approach and patient experience should be at the center of what we do.
Neil B. Minkoff, MD: I want to pull this in because this is relevant to what you’re talking about. There was a study trying to look at the overall cost of care and looking at the infused product. It’s a study by Gabriela Dieguez last year, and it was looking at not just the cost of a medication in MS but the downstream costs, the infusion costs, and so on. That was for ocrelizumab. Cheryl, I know that study was something you guys paid attention to. Could you talk about how you looked at the study and how that might have affected the way you look at the class?
Cheryl Larson: It’s 1 of the many—14 or 15—MS drugs on the market, and they brought it in at a lower cost. It’s a good product. You forget, from an employer perspective, about the total cost of care for some of these drugs. This was a good example: It might have been $65,000 from a WAC [wholesale acquisition cost] perspective per patient per year. It had to be administered under physician supervision, and they found that the average cost of administering that drug was over $100,000. Those are not always things that we’re thinking about. There’s some really positive this with that drug, but when you’re looking at total cost of care, it changes things.
There’s been a large shift from hospital and physician office administration to outpatient over the last 2 years, which has been increasing costs for employees and their family members as well as for employers. It’s because there are more administration fees and mark-ups that can be retained by the physician groups through the outpatient services vs. pharmacy or office administration. We believe that’s wasteful for the plans. I don’t know how there are doctors who are covering or they’re recommending the drug, but the payers—whether it’s the health plan or the employer—have to be looking at the cost in the end.
We talked earlier about self-injected drugs and some of the other drugs that are coming to the market that will hopefully address those problems. We tell this to pharmaceutical manufacturers that are bringing new drugs to the market all the time: “You have an opportunity to change the dynamic, the future before the government steps in and tells you what you can charge for something.” We’re hoping that, for the new drugs that are coming to market, they’re examining what the total cost of care will be because it matters.
Michael Fine, MD: Neil, I want to make 1 comment on that study. I agree with Cheryl that the infusion of these drugs oftentimes costs far more than the drug costs, but that’s because it’s being done at a site like a hospital, where the markup is egregious. If these drugs were reimbursed at the ASP [average sales price], they would be far less than even some of the self-administered drugs. The problem is that we don’t have an overlying system that controls the monopoly power that many hospitals and hospital systems have. That’s what’s driving up the cost of care, and we have to figure out how to address that.