Biotechnology Healthcare - June 2008 - (Page 44) Brieana Buckley, PharmD, MHP, tracks growth hormones, RA, and MS agents, and coordinates with care managers. the new formulary did hold the expense down a bit. And, despite their increased use of growth hormone, plan members saw their coinsurance drop by more than 40 percent — meeting one of SelectHealth’s goals for the switch. Physicians have mostly switched their patients to the more expensive of the two preferred options, so more tweaking may be needed to get the results the health plan desires. She will look again next quarter and hopes to see a different slope to the expense line. ESAS: EVERYBODY’S HEADACHE Like every other health plan, SelectHealth has been monitoring the news about dangerous side effects from the overuse of erythropoietin-stimulating agents (ESAs) — and considering how to respond. Restricting the products is difficult, because they are dosed frequently and require upto-date lab results to determine appropriate use. Giving physicians free rein, though, poses other risks. In March, the U.S. Food and Drug Administration urged caution, following reports that overuse — and, in some cases, even recommended doses — are associated with increased risk of death, blood clots, and other problems. Meanwhile, the Centers for Medicare and Medicaid Services proposed a new coverage policy that further complicated the issue.1 “It is so much more conservative than the 44 BIOTECHNOLOGY HEALTHCARE · MAY/JUNE 2008 FDA-approved label on these products, it confuses physicians,” Mitchell says. “It does not make sense.” SelectHealth, with an ESA bill of several million dollars each year, is part of an integrated system — Intermountain Healthcare — and at this writing, the entire system was planning a review of ESAs. Of course, the safety issues associated with ESAs translate into financial issues, as patients who suffer side effects rack up ancillary costs. Meanwhile, the manufacturers have approached the plan, seeking a preferred-status contract. That’s why Mitchell received a last-minute request to present ESA utilization, cost, and other trends for today’s injectables committee meeting. The word: SelectHealth’s quarterly expenditure for ESAs had dropped 30 percent in the past year. “That may be good for patients as well as payers,” says Mitchell. Knowing exactly what the data mean, however, requires some guesswork on Mitchell’s part. The number of members using three ESA products has remained steady, even as total use has fallen. If this means that physicians are curtailing inappropriate use, then Mitchell reasons that placing restrictions on these products may not be the best plan of action. One alternative may be to target only heavy-prescribing physicians. The injectables team decides to hold off on any decision and wait for more information from the FDA and CMS, and to see if member use keeps falling. “We are going to continue to monitor this for another quarter or two and see if this is a selflimiting problem,” Mitchell says. HAPPY DOCS, HAPPY HEALTH PLAN? When the challenge of managing specialty pharmaceuticals began to emerge, Eric Cannon, 1 Last July, CMS issued a new national coverage policy for ESAs, sharply curtailing coverage because of the FDA’s safety concerns. Critics of the new policy say it is not based on scientific evidence, and CMS has indicated it might reconsider the decision.
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