Biotechnology Healthcare - September/October 2008 - (Page 30)

imbursement, specialty pharmacy, disease management, and benefit design. It also communicates the viewpoints of diverse stakeholders, including MCOs, specialty pharmacies, physicians, and patients, whose responses converge on a common theme: collaboration. “Collaboration among healthcare stakeholders is the key to successful MS management,” says Peter Kwok, PharmD, principal of PNK Associates, in San Ramon, Calif. “This disease fits all the criteria for case management: a long-term, slowly progressive condition with clear, measurable outcomes; high expenditures; and a reasonable clinical return on investment. And it affects a relatively small number of patients.” MCO MANAGEMENT TRENDS On the whole, MCOs agree that biologics that offer a clear efficacy advantage over traditional therapies may be placed in a favorable tier position, and that the use of selfinjectables will continue to increase as long as safety and efficacy data support their use. But as costly biologics to treat MS continue to enter the market, MCOs are keeping a close watch on costs. Although MS prevalence and incidence are relatively small — MS affects 400,000 Americans, with 200 people diagnosed weekly, according to NMSS — the annual cost of treatment for this population is $20 billion. To ensure appropriate access to and utilization of MS drugs, MCOs have adopted a variety of strategies that mirror those commonly deployed to manage most biologic products: requiring prior treatment failure with a preferred drug before approving use of a nonpreferred product; limiting prescriptions only to the appropriate specialists; and using differential prior authorization to direct physicians to a preferred agent within a class of drugs (Figure 1, page 29). A sizeable share of surveyed payers that have not implemented these strategies say they plan to do so in the next 12 to 18 months. Another strategy planned within that time frame is the creation of tiered coverage with significant cost-sharing differentials for MS therapies (Figure 1). The emphasis on the use of cost sharing as a lever to control access concerns Brendan O’Grady, senior director of managed markets for Teva Neuroscience, in Kansas City, Mo. In trying to save employers money, he notes, some MCOs are replacing copayments with coinsurance for employees and their dependents, who — to their amazement — may be responsible for a $50 copayment one day and a $500 coinsurance the next time they are prescribed the same product. “That leaves few alternatives for patients,” O’Grady says. “Higher out-of-pocket costs often translate into patients becoming less compliant, because it forces them to stretch out their monthly allowance on drugs — or stop therapy altogether.” Either action, he says, has the potential to lead to a shift in costs from the pharmacy benefit to the medical benefit through increased physician visits and hospitalization. In some cases, he adds, high pharmacy cost sharing can result in patients switching to costlier products that can be obtained under the medical benefit for a lower copayment. Thirteen percent of MCOs surveyed cover self-injectable MS products under the medical benefit, and nearly 38 percent cover them under both the pharmacy and medical benefits, depending on the circumstance. In either scenario — whether it be poor outcomes resulting from noncompliance or patients moving to more costly products with better coverage on the medical side, he says, “The gains anticipated by the MCO may be wiped out. “Simple cost shifting for highcost biologics and specialty injectables alone is not the answer,” he says. “We need other tools, or quality of care will suffer.” Ensuring appropriate utilization, limiting use to U.S. Food and Drug Administration-approved indica- Table Reasons for establishing a prescribing checkpoint Objectives MCOs wish to achieve when requiring prior authorization for biologic or injectable therapies Ranked by importance; 1=highest rank, 5=lowest Objective Ensure appropriate utilization Limit to FDA-approved uses Ensure step-care therapy Limit use to compendia diagnoses Ensure appropriate lab work has been completed Ensure that patients are under the care of a specialist Mean rank 1.73 2.99 3.75 3.77 4.09 4.10 30 BIOTECHNOLOGY HEALTHCARE · SEPTEMBER/OCTOBER 2008

Table of Contents Feed for the Digital Edition of Biotechnology Healthcare - September/October 2008

Biotechnology Healthcare - September/October 2008 Openers Editorial/David B. Nash, MD, MBA Contents At a Glance: Multiple Sclerosis Drug Track Personalized Medicine Healthcare Reform’s Effects on Biologic Access Breast Cancer Status Testing: A Crapshoot With Deadly Odds Trends, Issues, and Perspectives In the Management of MS So High-Tech, Yet So Simple The Evolution of Ascertaining the Value Proposition Specialty Pharmacy Employer to Employer Health Plan Confidential Trends

Biotechnology Healthcare - September/October 2008

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