Biotechnology Healthcare - June 2008 - (Page 50) A careful, measured approach Like most health plans, SelectHealth uses a pharmacy and therapeutics (P&T) committee to manage all pharmacy products, including biologics. But, with the flood of new biologics hitting the market — along with evolving data about how and how well they work — the committee needs help. “The reality is that most P&T committees, ours included, do not have the expertise to truly evaluate these drugs,” says SelectHealth director of pharmacy Eric Cannon, PharmD. That is why SelectHealth uses a multipronged approach involving in-house pharmacists and network physicians to develop recommendations for P&T committee decisions. Doctoral-level staff pharmacists are responsible for tracking emerging therapies and how they compare with existing products. “Having a person on your own staff who understands the data provides the foundation on which you can talk with a group of physicians,” says Cannon, adding that such a person has to “balance street smarts with book smarts.” To that end, Cannon seeks pharmacists who not only understand the science behind biologics and the literature on them, but also have the ability to collaborate with physicians. Physician advisory groups, composed of such specialists as rheumatologists, oncologists, and endocrinologists, convene with SelectHealth regularly during the year to discuss new therapies, voice their preferences, and give feedback on proposed coverage guidelines. “If I look at Matt [Mitchell, featured in this story], I know he understands the science and is current on the published studies,” says Cannon. “He’s also willing to meet with the oncologists and listen, but he isn’t afraid to challenge their thoughts. Our relationships with our oncologists, even our rheumatologists, is open enough say, ‘This is the cost of the treatment, and the cost of using this treatment to generate one successful outcome,’” says Cannon. “We have modeled that in psoriasis, rheumatology, and some of the other areas where the study data and response rates are applied to a population with the actual costs.” Separately, an injectables guidance team meets monthly to consider management policies for all injectables, not just biologics. The team, using information gathered Cannon’s staff has modeled the cost of achieving one positive outcome with various oncology, rheumatology, and psoriasis therapies. that we can ask a question like, ‘Is this an issue of clinical outcomes or one of revenue generation?’” Even as SelectHealth is learning from its physicians, it uses the advisory group meetings as a teachable moment. “One thing we have done with our oncologists is to from the physician advisory groups and from research conducted by the staff pharmacists, sets and monitors goals for injectables, determines management strategies, and makes recommendations for benefit design changes. Eventually, that type of decision will have to be made. Mitchell believes clinical guidelines — perhaps developed by a broad group of constituents — will decide the balance between cost and benefit. “There is going to have to be more open discussion of this,” he says. “Decisions are going to have to be [on the basis of] ‘What is the absolute best practice?’ instead of ‘This study shows 2 to 4 weeks of extended 50 BIOTECHNOLOGY HEALTHCARE · MAY/JUNE 2008 survival.’” But for now, health plans decide which treatments will be covered for which patients. So tomorrow, Buckley and Mitchell will climb the ladder again, step back onto the tightrope, and do their balancing act. Lola Butcher, who writes about health policy and the business of healthcare, lives in Springfield, Mo.
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