Biotechnology Healthcare - June 2008 - (Page 42) A Day in the Life THEY PROVIDE THE PROOF WHEN TOUGH DECISIONS WHEN TOUGH DECISIONS BY LOLA BUTCHER Contributing Editor M atthew Mitchell, PharmD, MBA, MHP, does not look like a tightrope walker, but he is paid to perform a balancing act. No spangled outfits or dancing elephants to share the spotlight. Cheering crowds? Not likely. Mitchell is the manager of pharmacy services for SelectHealth, one of the largest health plans in Utah, insuring or administering benefits for more than 500,000 members. His job includes determining reimbursement requirements for novel and existing therapies. He does not make the decisions alone, of course, but he is responsible for collecting, analyzing, and summarizing clinical, claims, and cost data — ABOUT THIS STORY In a few detached corners of healthcare, the feeling has developed that third-party payers must address a lack of in-house expertise about biologic therapies if they are to make informed coverage decisions. Several members of the BIOTECHNOLOGY HEALTHCARE editorial board have suggested that an in-house scientist trained in biotech, who could evaluate specialty pharmaceuticals, would be a valuable addition to a P&T committee. We set out to find one. We surveyed 30 health plans — and found none. In the process, though, we came across a handful of plans that take a careful and rational approach to coverage policy development. In Utah, SelectHealth has a dedicated team of doctoral-level pharmacists who study biologic therapies and outcomes, model costs, help to develop guidelines, and create collaborative relationships with physicians. Contributing Editor Lola Butcher followed two SelectHealth team members for a day as they dealt with issues related to oncologic products, growth hormones, erythropoietin-stimulating agents, and a host of biologics in the pipeline. Photographs by Nick Sokoloff and making recommendations — that inform SelectHealth coverage decisions. Every day, Mitchell must balance the risk of a drug’s dangerous side effects with its potential for therapeutic success. Or the rationale for a costly popular therapy against guidelines that recommend use of a less-expensive near equivalent. Or the possibility of antagonizing physicians against the prospect of saving millions of dollars through rational therapeutic choices. In a typical year, Mitchell’s work will help influence pharmacy expenditures of about $225 million and a medical spend of more than $100 million. Physicians and patients always want more treatment options and freedom to choose; health plan officials want cost-effective treatments that produce reliable health outcomes. Society at large wants it both ways. So Mitchell and his peers, like those at health plans around the country, tread carefully on the tightrope, knowing the balancing act will become more difficult as the biotech industry pumps out new products that bring unprecedented hope, hype, and high costs. He and his colleague, Brieana Buckley, PharmD, MHP, allowed BIOTECHNOLOGY HEALTHCARE to watch SelectHealth make decisions about injectables and other specialty products. We tracked them on the first Tuesday of the month — Sept. 4, 2007 — because that is when SelectHealth’s injectables guidance team meets. That committee, comprising pharmacists, physicians and health plan administrators, acts as a sort of stabilizer for injectable coverage. Other support comes from physician thought leaders — oncologists, endocrinologists, or other specialists who convene to share their opinions and experience with SelectHealth pharmacists. This day’s work will influence decisions about dozens of products, including biologics. These decisions will affect the plan, its physicians, and its members. Let’s take a walk on the rope. 42 BIOTECHNOLOGY HEALTHCARE · MAY/JUNE 2008
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.