Biotechnology Healthcare - July/August 2008 - (Page 24)

as easy to pull off with biologics. ones who are usually healthy or just Reference pricing infers therapeutic want another investment.” equivalence — something that is The fallacy of the HSA, Kwok arnot easy to demonstrate for large gues, is that most health plan undermolecules with heterogeneous pro- writing is experience rated. “When a tein structures and complex modes lot of healthy people migrate toward of action — the very thing vexing a certain type of benefit design [such the creation of a regulatory path- as an HSA], those who remain in the way for biosimilars in the United system skew the availability of exStates. Expect fierce formulary perience — the sick will wind up in management battles as biosimilars more traditional arrangements, and become available. you end up back at square one in Employer benefit plans have terms of affordability. That makes it changed in recent years. The value- even more difficult for employers, based benefit designs being piloted the government, and other payers to notwithstanding, many of these get a handle on benefit design.” new offerings have amounted more Well, if the purpose of benefit deto cost shifting than insign is not to withhold novative benefit mantreatment, what’s a agement. More than payer to do? half of employers that “I’ve always called provide health benefits that the ghoulish facnow offer some type of tor,” responds Howatt, health savings account, at Molina. “Do you which poses challenges make administrative defor the average concisions that have bad sumer who has little It won’t be easy, but outcomes for the comknowledge or usable in- “When CMS says this pany in terms of finanformation about spe- makes sense I cial consequences? We cialty pharmaceuticals. think health plans will try to leave those look at [QALY analyThough HSA uptake thoughts behind when ses] more seriously,” has been slow, Kwok says Aetna’s Mark we’re choosing the best foresees growth in this Rubino, MHA. course for the patient.” market — if not for all Some in the insurance the right reasons. industry may find a certain attracStart with the idea that money in tiveness to strategies that prevent an HSA is set aside on a pretax sicker patients from enrolling, basis. “You can tuck away those an- Howatt admits, “but it destroys the nual amounts you pay into them or insurance concept. And, just possiput them into investment CDs,” he bly, if you do enough of that, you says. If you use the HSA for first- get hit somewhere else.” dollar coverage, then once the Rubino, at Aetna, thinks that the money has been exhausted, you go cost-effectiveness research being into catastrophic coverage. “With done on quality-adjusted life year patients who require a biologic, it’s (gained) — the much-maligned a given that the HSA will be de- QALY measurement of health impleted in no time. provement — may offer an answer. “So guess what?” he asks, rhetor- Now being tested by CMS for ically. “The people who migrate to- Medicare, QALY analyses are used ward HSA kinds of benefits are the in cost-utility analyses to measure 24 BIOTECHNOLOGY HEALTHCARE · JULY/AUGUST 2008 health improvement by combining mortality- and quality-of-life gains. Adoption by CMS may push payers and employers toward using QALYs in making coverage decisions. It’s not going to be easy, Rubino says. “First of all, QALYs give you a soft number. It’s different with the return on investment for a statin — you can demonstrate the decrease in heart attacks and cardiovascular events over four years, or sooner. With chronic diseases, you are never going to cure patients, at least with the drugs we have now. But when CMS says, ‘This makes sense, and we’re going to use these studies to determine coverage for Medicare,’ then I think health plans will look at it more seriously.” Or not? Rubino himself wonders why some health plans would do it if the payback were 10 or 20 years after the member left the plan. 5 Genomic diagnostics and genetic risk management In his 2005 article, Baker recalled a 2002 meeting of health plan representatives who discussed the management of TNF-α inhibitors. Those present agreed that while available agents might work differently in different patients, that did not necessitate coverage of every available therapy. The burden of proof, they thought, is on manufacturers to show allelic heterogeneity at the molecular or genetic level. Granted, molecular tests for HER2 breast cancer can enable physicians to prescribe trastuzumab (Herceptin) with relative certainty about a patient’s likelihood of response, but

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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