Biotechnology Healthcare - July/August 2008 - (Page 22)

require biologic therapies, the role of DM is being questioned. “In a prior life, where I ran DM services, we were focused on when to start a biologic,” says Howatt. “Nobody has really addressed, that I know of, whether in RA, for example, pulsing the drug makes more sense, or if drug holidays diminish side effects. In fact, in looking at the pharmacoeconomics of therapy, we don’t know what the persistence is.” Though payers have used DM primarily to gauge how long a patient should stay on a biologic, there is no consensus about how to define therapeutic endpoints. “It seems that once these drugs get started, they rarely get stopped,” says Howatt. “Some of these drugs are so new, that kind of research hasn’t been done.” 3 Preferred products and narrowed categories Some biologics, such as growth hormones, hepatitis C agents, and some MS therapies, are perceived as being interchangeable, and designating preferred products among them is a niche that some specialty benefit management companies (such as Ancillary Care Management and Icore Healthcare) have embraced enthusiastically. More complex biologics, such as tumor necrosis factor (TNF)-α inhibitors used to treat RA, have considerable structural, binding, and functional differences, making it more difficult to designate preferred biologics for these categories. “To create a formulary that is interchangeable just doesn’t work for some disease states,” says Rubino. And although several companies make insulin and growth hormones, that isn’t so with infliximab (Remicade) or interferon beta-1a (Avonex), says Rubino. “Even then, the formulary would work only for patients new to therapy. It’s perfectly appropriate to try interferon beta-1a for MS before interferon beta-1b (Betaseron) in a new patient, but it isn’t appropriate to switch someone the other way round if that person is being controlled well with Avonex.” Molina cannot use tiered formularies because it serves Medicaid and other government program members exclusively, but it is looking at options for therapeutic interchange, administration routes, and dosing schedules. In some limited cases, biologic interchangeability has provided cost savings. “We did a study, first in our Washington plan and then we recommended it to our other plans, with regard to choosing a specific growth hormone agent, and it has resulted in substantial cost savings without affecting quality of care,” says Howatt. “Now, there will always be dissenters — and we try to honor those on a case-by-case basis — but picking a specific agent and using that agent across the plan has made a huge difference for us in unit cost.” In this instance, Howatt is referring specifically to growth hormones, but he also believes that some of the RA medications may be interchangeable. From a pharmacy management standpoint, Rubino thinks the designation of preferred therapies works best with oral medications — Aetna requires precertification for oral traditional and targeted therapies — but less so for other therapies, especially those not subjected to traditional medical management techniques. Aetna does not require precertification for self-injectables, for instance, so if a patient is diagnosed for MS and the physician suggests interferon beta-1a, that is what the patient gets. Overall, most payers and employers have not moved their members who need biologics to a preferred product, even when choice exists in a therapeutic category. “Take growth hormones,” says Baker, “and you see that the products are truly interchangeable. Yet most health plans are covering all or most of them. There’s no attempt to say, ‘We want only one or two of these products, and the rest are not covered.’ The same is true with the red blood cell growth factors. Notwithstanding dosing differences, they are identical.” Moreover, says Baker, higher cost sharing for nonpreferred therapies has not been sizable. Which brings us to the next stage of the Zitter continuum…. 4 Benefit design innovations and cost shifting Various aspects of benefit design are intended to serve as levers on supply and demand. The important thing is not to create a barrier to access, but to engage the patient or physician, depending on the technique. On the demand-management side, cost sharing is at the top of the list of techniques intended to engage the patient. “Most payers would love to have coinsurance, because that’s more realistically aligned with the cost of biologics, typically at 20 to 30 percent,” says Kwok. Coinsurance has proven 22 BIOTECHNOLOGY HEALTHCARE · JULY/AUGUST 2008

Table of Contents Feed for the Digital Edition of Biotechnology Healthcare - July/August 2008

Biotechnology Healthcare - July/August 2008 Openers Contents Editorial/David B. Nash, MD, MBA Drug Track Health Plan Confidential Rheumatoid Arthritis A Decade of Trial, Error, False Starts, and Hope What Path Will Comparative Effectiveness Research Take? RA Therapies in Development: A New Generation of Relief Assessing the Full Impact of RA on Employers and Payers Stem Cells: Health Insurance You Can Bank On Specialty Pharmacy Employer to Employer Personalized Medicine Trends Clinical Briefs

Biotechnology Healthcare - July/August 2008

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