How to Better Manage Specialty Drug Spend for Chronic Conditions

Didn’t have time to attend our recent webinar on managing chronic conditions? Don’t worry – we’ve got you covered with a recap!

FINANCIAL AND CLINICAL IMPLICATIONS OF CHRONIC DISEASE

According to the most recent health expenditure data, the U.S. spent $3.8 trillion on health care in 2019.¹ Patients with chronic diseases, such as heart disease, diabetes, cancer and arthritis, disproportionately drive health care spending, accounting for an astonishing 90% of the health care expenditures.²

Unfortunately, despite these very high costs, plans are seeing suboptimal outcomes, including low rates of adherence for medications used to treat chronic conditions. With high costs and poor outcomes, it’s no wonder chronic conditions have become a major area of focus for plan sponsors.

During a recent webinar, Laura Jester, PharmD, CSP, Nicholas Skalitzky, and Amanda Lee, PharmD, discussed solutions that drive real change for chronic condition populations, including how to:

Look more holistically at drug spend across benefits

Link pharmacy benefit tools on the PBM side to drugs that are traditionally covered under the medical benefit

Connect and engage with members to improve outcomes and overall health

creating alignment across benefits

Unfortunately, the strategy behind drug coverage and management often differs between the pharmacy and medical benefit, creating a significant barrier for plans. Plans might be implementing specialty drugs on the pharmacy side, but not the medical side, resulting in misalignment of drug management for chronic conditions.

These tips and tools can help bridge the gap between pharmacy and medical benefits, thereby reducing costs and improving the quality of care.

Review specialty drugs in the medical marketplace to determine appropriate utilization management and coverage strategies.

TIP: Take advantage of your PBM’s Pharmacy and Therapeutics (P&T) Committee, which thoroughly reviews clinical aspects of drugs in the marketplace, considers the financial landscape and analyzes associated costs compared to other therapies currently available.

Integrate medical data with your pharmacy benefits data to help identify factors that drive your spending and improve care management for chronic populations.

TIP: Your medical benefit spend is made up of more than just drugs – it includes procedures and codes that can be complicated and confusing. Take advantage of your PBM’s experience with complex pharmacy data trends to turn lines of J-codes into data insights that will help you easily identify the factors that are driving your spending.

Apply PBM network reporting capabilities to better understand member access to pharmacies and identify opportunities to improve care.

TIP: The same tools used to monitor adequate geographical access of pharmacy networks can be used to identify more convenient infusion options for members. Explore this opportunity to integrate with your PBM.

addressing chronic condition challenges

Despite the massive spending on health care and innovative new technologies hitting the market, significant health challenges still exist for members with chronic conditions. To provide you with a little more insight, these alarming statistics on adherence demonstrate an opportunity for clinical intervention.

20% of prescriptions are never filled³

50% of prescriptions are taken incorrectly³

28% of patients fail to refill a prescription on time⁴

22% of patients take a lower dosage than prescribed⁴

With the goal of reducing health care spending, while simultaneously improving member health, clinicians must take advantage of every opportunity with a member to assess their personal barriers to adherence. Within programs such as Medication Therapy Management (MTM), a member’s understanding of their medications, and the best way to monitor their efficacy can be checked. It’s also an opportunity to identify side effect concerns that may be prompting the member to reduce their dose.

TIP: Most Medicare Part D plans include MTM programs, but MTM services can be provided to any patient population that would benefit from personalized member-level support, specifically patients with multiple chronic conditions and an extensive medication regimen.

Chronic conditions continue to be drivers of health care spend, while at the same time, optimal treatment outcomes are frequently not met. Consider how your PBM can help you better manage specialty drug spend for chronic conditions, increase medication adherence, close gaps in care and improve health outcomes.

Want to learn more? Watch the webinar on-demand today for more tips and tools to help you lower costs and improve the quality of care for chronic populations.

Center for Medicare & Medicaid Services. National Health Expenditures 2019 Highlights. https://www.cms.gov/files/document/highlights.pdf. Published December 16, 2020. Accessed September 22, 2021.

Buttorff C, Ruder T, Bauman M. Multiple Chronic Conditions in the United States. RAND Corporation. https://www.rand.org/content/dam/rand/pubs/tools/TL200/TL221/RAND_TL221.pdf. Published 2017. Accessed September 22, 2021.

Neiman AB, Ruppar T, Ho M, et al. CDC Grand Rounds: Improving Medication Adherence for Chronic Disease Management — Innovations and Opportunities. Morbidity and Mortality Weekly Report (MMWR). http://dx.doi.org/10.15585/mmwr.mm6645a2. Published November 2017. Accessed April 14, 2020.

Medication Adherence in America. National Community Pharmacists Association. http://www.ncpa.co/adherence/AdherenceReportCard_Full.pdf. Published 2013. Accessed April 14, 2020.