Biotechnology Healthcare - November/December 2008 - (Page 45) specialty pharmaceuticals may vary significantly. For rare conditions, such as Gaucher disease, one company may have nobody in need of imiglucerase (Cerezyme) or idursulfase (Elaprase), while another similar-sized company may have one or even two patients taking one of these medications, at $200,000 or more annually. Even for more common conditions (rheumatoid arthritis or hepatitis C, for instance) that are treated with specialty products, the fast market emergence of newly approved biologics makes trends difficult to predict. “The key issue is that benefits designs are generally focused on traditional drugs that are relatively inexpensive,” Vogenberg said. “But uniformly among specialty pharmacy products, these are very expensive drugs, so your employees hit their out-of-pocket maximum faster, which means more money out of the employer’s pocket.” Vogenberg is advising larger clients to put together a long-term plan of action — at least five years into the future — that plots benefit design and employee-engaged management with respect to specialty drug utilization. “It’s a whole different world that employer- and other payer-sponsored plans are going to face,” says Vogenberg. “It’s taken consumer-directed healthcare plans a decade to gain traction, and it may be the same for specialty pharmacy — so employers had better be ready.” Relative importance of prescription drug benefit components In a recent survey of employers, specialty pharmacy trend ranked only 13th in relative importance among 18 aspects of the pharmacy benefit. On a scale of 1 to 5, a 5 denoted high importance. Prescription drug benefit component Employee access Customer service Generic dispensing Overall cost trend Pricing Vendor effectiveness Formulary comprehensiveness Vendor confidence Per-prescription drug costs Account management Contracting and rebates Reporting Trend to specialty drugs Safety of generic drugs Hidden costs Increased utilization Network management Lack of vendor confidence to act in the best interests of the client Source: Buck Consultants 2008 Average score 4.59 4.58 4.53 4.44 4.41 4.38 4.16 4.15 4.10 4.07 4.03 4.03 3.95 3.85 3.84 3.75 3.70 3.52 THE 500-EMPLOYEE COMPANY Specialty pharmacy issues for mid-sized companies of 500 employees (approximately 1,200 lives) can be somewhat tricky. For companies that are self-insured, their issues will closely mirror those of 5,000-employee companies, while those that are fully insured will have issues similar to smaller employers. “There may be some unique issues for a mid-sized employer that is fully insured yet offers a consumer drug plan,” Vogenberg said. “The issue comes into play when an employee hits an annual deductible or out-of-pocket maximum for the year. But if [an employer contracts with a] health plan and is fully insured, specialty pharmacy costs are mostly going to be normalized over several million people. So, while you may or may not see an annual bump in rates, [trends] will be more stable.” THE 50-EMPLOYEE COMPANY While Vogenberg spends most of his day thinking of new plan strategies or crunching numbers for the big boys, Michael S. Jacobs, RPh, Georgia-based national clinical practice leader for Buck Consultants, spends a lot of time sweating about the little guy. “To me, one of the scariest parts of healthcare in the next 10 to 15 years is going to be the impact of these specialty drugs on the smaller organizations, the guy who owns the tool and die company with 71 employees who is buying fully insured products,” Jacobs said. “For him, if he has one employee on a $70,000-per-year therapy, that is going to raise the cost to his entire population $20 per employee per week. Once that cost gets rolled in, he’s dead meat.” Jacobs admits that it is unrealistic for a benefits manager at a small employer that must also juggle staffing, payroll, and accounting duties, to expect to grasp the complexities of specialty pharmacy. Reaching out for help, Jacobs feels, is not only realistic, but necessary. “Most small employers should be able to find a broker or a consultant or even a local university pharmacist to help them understand why these drugs are hitting the market now and educate them on the fact that they can expect a return on investment for these drugs. “Smaller employers need to be aware that they can make demands of their providers. There are options — you can go to Aetna or Cigna or United (Healthcare), or the Blues. Employers have to start taking care of themselves by making sure that their providers are accountable for their expenditures.” Scott Kober is a freelance writer in Philadelphia specializing in medical issues. NOVEMBER/DECEMBER 2008 · BIOTECHNOLOGY HEALTHCARE 45
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