Managed Care - August 2012 - (Page 40)

specialty pharmaceuticals. They may also want to work with pharmaceutical companies on management of mainstream diseases such as diabetes with comprehensive programs encompassing diagnostics, treatments, adherence efforts and personalized medicine methods. Specialty pharmacy The growth in specialty pharmacy volume and increases in specialty drug costs will require PBMs to change their approach to specialty pharmacy. A significant amount of specialty pharmacy costs comes through the medical benefit, which is not subjected to the PBMs’ utilization management programs. The top tier PBMs are working on strategies to merge medical claims data with the pharmacy claims data, which will eliminate gaps in care and enable improved outcomes. This merging of data is leading to the creation of a new specialty pharmaceutical benefit. Analyzing pharmacoeconomic outcomes data on all of a PBM’s patients can provide valuable trend information and help reduce costs. Pharmacogenomics and pharmacogenetics will be employed as part of the prior authorization (PA) process, along with biomarker testing. If these tests are required as part of the PA process, no longer will PBMs have to pay for each patient’s use of an expensive drug to determine responsiveness. Instead, drug responsiveness will be determined before the drug is administered. The specialty pharmacy’s use of care management programs can yield significant financial benefits for PBMs. In addition, mobile health technologies play a key role in the PBM’s management of specialty medications. These technologies can be used as medication reminders to improve adherence and provide the patient with refill reminders. Product/service pricing As more brand products convert to generic and more specialty products come to market, average wholesale price and rebate-based pricing methods will be supplanted by risk-sharing between drug companies and PBMs. These models ensure clinical outcomes for a negotiated or contracted price. As pharmaceutical companies become more active players in the care delivery system, they will have greater access to providers, patients, and payers, resulting in shorter and more effective product develMANAGED CARE / AUGUST 2012 opment cycles that continually improve the quality of care. As specialty products become mainstream, financial incentives along with performance- and outcome-based contracts will become the norm in the PBM world. External market factors will force the customer service component of the PBM to find innovative ways to deal with a growing number of members and a rapid expansion of chronic disease within the general population. As the PBM product mix becomes heavily oriented toward specialty drugs, the customer experience must be revamped. Specialty drugs are more complex and typically require infusion, either at home, in a physician office, or in an infusion clinic. Anticipate patient needs PBMs must transform the customer-service operation into a high-touch proactive service organization and be able to better anticipate patient needs. The high costs of specialty drugs, the complex route of administration, and other factors increase the need for a customer service model that delivers fast, personalized decision making. PBMs will need many more employees with clinical expertise to engage in utilization management strategies such as prior-authorization programs, step-therapy programs, dynamic formularies, and biomarker testing. ICD-10 diagnosis coding, payersponsored trials, and risk-sharing programs will also require highly trained employees. PBM customer services operations will need to address these questions: • What attributes of customer experience are important to customers? • How can data on performance relative to those attributes be captured and analyzed? • Where can the biggest difference be made? • What is the likely impact on revenue and costs? • What must be done and when? Timing is key The effort to transform the PBM industry must start today while the transition to specialty medication is in its early stages. The sooner they can do this, the more successful they will be. The views expressed in this article are those of the author and do not necessarily reflect the views of Ernst & Young. 40

Table of Contents for the Digital Edition of Managed Care - August 2012

Managed Care - August 2012
Editor’s Memo
Contents
Legislation & Regulation
News & Commentary
Medication Management
Evidence Review
Compensation Monitor
Private Exchanges: Practice Makes Perfect
Hospitals and Providers Ganging Up on Plans?
Q&A: Kaiser Permanente’s Sharon Levine, MD
God Save the Health Care System!
Future Points to Greater PBM/Plan Cooperation
Formulary Files
Plan Watch
Tomorrow’s Medicine
Outlook

Managed Care - August 2012