Biotechnology Healthcare - July/August 2008 - (Page 26)

scribing regimens suggests a need to look more closely at a patient’s treatment regimen, address utilization management issues, and assess therapeutic alternatives. “I think that’s a good first step in comprehensively managing biologics, and I think that is the wave of the future.” Other health plans will build those kinds of systems too, he adds, because they will have a common platform and the technology to do it. “Within a year, most of the large payers with strong financial resources will follow the Anthem model. The smaller payers will have to wait until the technology is offered to them by a vendor.” Alignment. This is a buzzword for the idea that medical and pharmacy ultimately cannot coexist in silos, and it’s what many have said is needed to generate processes that will improve medical outcomes. “Without alignment, it’s not going to happen,” Kwok emphasizes. When Kwok talks about alignment, he is echoing the Deloitte report’s contention that aligning stakeholder interests is the only path to controlling healthcare expenditures. CMS’ current focus in that regard is its pay-for-performance initiative, which bases reimbursement on clinical outcomes. Private payers are watching closely to see if CMS can collaborate with quality improvement and other organizations to translate its data into benchmarks. Drug-delivery improvements. Oral biologics to manage hepatitis, MS, RA, some cancers, and other chronic diseases will become more common. Kwok thinks this will force a redefinition of SP. “When you have oral products that cost you the same as an injectable over the course of a year, then how do you define the role of the SP?” Treatment optimization pro- grams (TOPs). A TOP serves many functions, but above all, it is intended to measure cost and medical outcomes. Unlike DM, which is population-based, a TOP is individualized. The goal is to achieve optimum health outcomes through a balance of quality-of-care and costmanagement processes for chronic diseases that have measurable outcomes, a reasonable clinical and financial return on investment, require expensive drugs, and have a manageable patient population. A TOP uses claims and clinical outcomes data to intervene proactively — having laboratory work done at the right time, for instance, when outcomes suggest that a patient’s current treatment regimen isn’t helping as expected. The idea is to prevent disease progression through better compliance and persistence — especially for conditions such as MS and RA, where costs associated with disability progression and suboptimal therapy can be quantified. Targeting interventions to prevent acute relapses and disability progression in MS, he says, is an example of “where the savings can be documented easily during the course of the disease.” The key to making a TOP work is to be able to identify baseline utilization metrics, and through proactive interventions facilitated by pharmacists in SP practice, quantify savings and quality-of-life improvements before and after these interventions. Kwok likens TOPs to medication therapy management, and thinks it is an “effective way of creating alignment among payers, medical and pharmacy providers, and patients, and a new way for pharmacists to be paid on the basis of outcome, rather than by the product dispensed.” Manufacturer initiatives. Hudes, at Deloitte, puts some of the onus of controlling biologic expenditures on manufacturers. Healthcare spending increases are not sustainable, he says, “so industry must come up with collaborative and long-term solutions. Biotech companies are in a good position [to do this] because of the cost-benefit profiles of their products.” The burden of proving a drug’s value extends well beyond approval and launch of a drug, presenting manufacturers with an opportunity to educate payers and employers and overcome their skepticism. “They need to be prepared to do ongoing postmarket surveillance on the safety and efficacy of their products. As we’ve learned from some setbacks that have beset the pharma industry, companies must continue to build the case for them with increased clinical experience and market intelligence.” The process of managing biologics has followed the 5-stage continuum, but it has proven to be less of a gradual, stage-to-stage progression than a process whereby payers are trying out new ideas at almost every stage. The laborious work of seeking a balance between cost and access while improving health outcomes is slow and the magic formula may be years away; every new strategy designed to address issues and problems in one area seems to create new issues and problems in another. In the end, payers may find they can do only so much until other stakeholders redefine and align their interests. Says Kwok, who feels passionately that quality of care will increasingly be a vehicle for maximizing value, “Cost is important — we should never apologize for affordability of healthcare — but cost has to be equated back to quality, or more important, to acceptable quality.” 26 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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