Supporting Cross-Benefit Management of Infused Drugs - Episode 11

Management of Drug Spending and Impact of COVID-19

The panel reviews an example of monitoring and managing the cost of medical and pharmacy spending with a biosimilar and discusses the effect of COVID-19 on the route of administration for high-risk populations.

Neil B. Minkoff, MD: Let me pull it back because we’re talking about trying to get at this level of integration. Are there any examples of a drug or molecule for which you’re monitoring the costs on the medical spend at the same time you’re monitoring on the pharmacy spend? If so, how do you go about doing something like that?

Eric, say somebody calls you asking for that information. Somebody is calling you about a drug for which you’re trying to manage or understand costs across the pharmacy/medical benefit. How difficult can that be for you? Is there a real-world example where you’re doing that?

Eric Cannon, PharmD, FAMCP: If you look at rheumatoid arthritis today, we’ve got several biosimilars out there for the infliximab molecule. As we have worked to be transparent about costs, not only have we worked to make sure that the cost estimator tools that exist on pharmacy and medical have the correct information, but now we have also asked about how we sync the information under those 2 systems. We’re not there yet, but we have done a good job with our providers, and our providers have bought into this notion of understanding what the available treatments are for them and what the net costs associated with those treatments are.

I wish there was some great outcomes story where we could say that we managed this across the benefits, and we’ve shifted all this cost, and we’ve saved all this money. However, it’s probably too early in the story at this point, but we’ve made a lot of headway in the last 12 months as we’ve looked at how that is going to shift. We’ve got examples in oncology now that we’ve got biosimilars entering into major categories, and we’re seeing significant savings that are coming as a result of it. The key for us now is going to be how we integrate some older treatments that have been around for quite a while that now have biosimilars with newer treatments that have genetic markers and targeted therapies. How do we differentiate between the outcomes of the associated 2? That’s the piece that is difficult for us going forward as we continue with new treatments to bring in more the genomics that play into targeting the therapy and finding the appropriate patient. We’ve never done some of that genomics work on some of the older treatments.

Neil B. Minkoff, MD: Cheryl, you were trying to come into this, please.

Cheryl Larson: I wanted to share that I specifically asked 1 of our employer members what an environment looked like when they switched from a medical benefit to the pharmacy benefit, and they also used the example of rheumatoid arthritis. They said that they saved about 2% to 6% of costs. The biggest barrier they had was that the J-code blocking was hard for them to implement. Although they did it, it’s going to take you a little bit of time to recoup those costs, but they decided to do it.

Neil B. Minkoff, MD: Michael, you brought this up. Kevin, I’d also love to hear any examples of places where you think that you’ve seen cost savings by moving a drug from the medical benefit to the pharmacy benefit, or if not the drug benefit, then the management.

Michael Fine, MD: We’ve done that in hemophilia. The trouble is that most federal regulations and a lot of state regulations don’t let you arbitrarily choose where you place a drug. You have to have a consistent policy and you can’t say, “I’m going to move this drug to the pharmacy benefit because it will potentially save us some money.” What we did do is we moved the hemophilia factors away from buy-and-bill to specialty pharmacy and home infusion. Even though it’s a medical benefit under the members’ schedule of benefits, and they pay it like a medical benefit, it’s really managed like a pharmacy benefit. It’s managed by a specialty pharmacy who also does a home infusion. They negotiate for the lower cost factors and try to convince the hematologists to use them. You can do this without changing where the benefit is because that requires a lot of regulation. That’s where a lot of payers are going. They’re going to say, “OK, it’s still going to be a medical benefit,” and they’ll pay it according to the medical drug benefit, but it’s going to be managed like a specialty pharmacy drug.

Neil B. Minkoff, MD: Kevin?

Kevin U. Stephens, Sr, MD: It’s the same thing. That’s a great example of a drug that we have had savings with. For the future, particularly after COVID-19 [coronavirus disease 2019], we have to be more open to other new technologies and use technology to a greater extent, even with Zoom and all the video capabilities. With children, most children are studying from home, and they have some type of technology to go to school these days. With that being incorporated into families, that gives us a few arrows in our quiver to where we can go safely and do other things like home administer drugs no matter where it is. We have other safeties that we can incorporate to get a better product. The bottom line is the patient. If they can’t afford it, then it doesn’t matter where we say it’s administered or whether it’s a medical or pharmacy benefit. If they have adverse effects that they can’t deal with, then they won’t take it. The bottom line, again, is that they have to get better. It has to work, so we have to put all that into play, as long as we keep the patient in the center and have patient-centered care based upon the nuances, whether it’s the social determinants of health or whether it’s the pharmacy administration. If the doctors and the hospitals can’t make a profit, then they can’t stay in business. It’s important for everyone.