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As the costs of specialty drugs continue to rise, managing the expenses associated with specialty pharmacy has become increasingly challenging. In order to keep costs in check without compromising patient care, healthcare providers need to have access to the right data and analytics.
Prescription drug costs have been rising at a faster rate than other medical plan costs. Large employers have experienced prescription drug cost growth averaging 7 percent in recent years, with specialty drug costs increasing by 11.4 percent. In this scenario, employers need to explore ways to manage this growing cost. Here are a few things that employers can do to identify future opportunities to improve plan performance:
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Analyze Drug Spend: Employers should analyze drug spend across both medical and pharmacy benefits and project how those costs may escalate over time. This could influence plan design decisions like excluding coverage under the medical plan for some drugs to steer members to a specialty pharmacy.
Re-evaluate Rebates: Employers must re-evaluate the financial value of specialty pharmacy rebates under the medical plan and negotiate contract language specifically focused on specialty medication.
Optimize Site of Care: Employers should know where plan members are receiving infusions and actively work with their PBM/carrier to drive distribution to the most efficient channels.
Control Out-of-pocket Costs: Employers should examine PBM programs associated with their specialty pharmacies that maximize the amount of support the drug manufacturers may be willing to contribute to members’ out of pocket cost, potentially lowering employees’ cost to zero.
Integrate Care Management: Employers need to assess the care management integration between the PBM, specialty pharmacy, and medical case management. Employers should look for repeated emergency room use or hospital admissions that may indicate opportunities to minimize drug side effects or other disease management interventions.
Mitigate Catastrophic Claims Risk: Employers should look at their population demographics, diagnoses, and claims history to gauge the risk of catastrophic cases that might require the use of cutting-edge and extremely expensive medications or gene therapies. Then they can assess ways to mitigate the risk via authorization programs, stop loss coverage, and captives.
Employers should leverage their plan data to manage specialty drug costs. With new gene therapies on the horizon, it’s essential to get these processes in place so that employers are ready when they come to market. By implementing the above-mentioned strategies, employers can help control costs and ensure that their employees receive the best possible care.
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