Case management programs or high-touch care delivered by pharmacists are critical components in the management of specialty medical drugs.
The United States will spend approximately $577 billion on prescription drugs by 2021.1 About half of this spending ($285 billion) was attributable to specialty drugs.1
While specialty drugs account for about 50% of prescription drug spending, only 1%-2% of patients use specialty drugs. Special drugs are billed through the pharmacy and/or medical fees, depending on several factors.
Given the significant costs associated with specialty drugs, it is important that these drugs are used and administered properly. This article provides a high-level overview of use management strategies for specialty drugs obtained through the medical benefit.
Pre-authorizations (PAs) are an essential tool to ensure that healthcare providers adhere to the plan’s formulas and that members receive the medication that is safe, effective, and valuable. PA criteria are determined by several factors.
First, health care providers are requested to identify clinical need and therapeutic rationale, especially for cases where there may be a cheaper, equally effective alternative. Subsequently, PAs can be used as a tool to promote appropriate drug use and prevent abuse.
For example, many PAs for specialty drugs have to come through specialists, such as chemotherapy from oncologists. This can reduce the chance of side effects and possibly ensure the success of the treatment, given the expertise of the healthcare provider.
Finally, PAs can be used to reduce safety concerns (e.g., REMS programs, drug interactions, lab testing) and avoid payments associated with cosmetic use that are often benefit exclusions. In short, PAs, when done properly, can be a tool for cost control and optimization of results.
Site-of-care management is another tool to reduce the costs of specialist medical drugs. Specialist medical drugs often need to be administered by a healthcare professional.
The application site may include a home, physician’s office, or outpatient hospital setting. When a drug is billed in outpatient hospital settings, the cost incurred for the plan is about 1.5 to twice that of physician offices.2
Therefore, strategies that enable drug delivery in lower cost locations can reduce drug spending on health plans. In an analysis using the IBM MarketScan database, researchers found that transitioning drug delivery from outpatient hospitals to clinicians could save about $14.1 billion, which is about 1.5% of total health care spending for the United States. members included in the analysis.2
This translates into a savings of approximately $110.03 per member per year.2 PAs can be a resource to facilitate appropriate care center management. Other strategies for generating savings at the site-of-care include provider network management, benefit design changes, and modified benefit plans/incentive programs.
Rounding vials is another tool to reduce potential waste. Many specialty medical drugs are available in single-use vials, with dosage determined by weight.
As a result, there can be variability in the doses administered, which can lead to wastage. According to a study, the amount of waste per drug can range from 1 to 33%.3
In vial rounding, the dose to be administered is rounded to the nearest dose or in a vial. Margins of + 5%/ + 10% is typically applied during the completion of the vials. In a recent analysis conducted at the Mayo Clinic, the health system was able to generate savings of approximately $7.3 million within 6 months of implementing the automated vial completion program in their electronic health record.4
Weight-based dosing programs take advantage of differences in dosing schedules to generate savings. Certain medications, such as pembrolizumab, are given in a fixed dose or in weight-based regimens with comparable efficacy. Pembrolizumab treats cancers such as melanoma, lung cancer, head and neck cancer, Hodgkin lymphoma, stomach cancer, cervical cancer, and certain types of breast cancer.
In a hypothetical budget impact analysis, researchers found that administering pembrolizumab at a weight-based dosage could result in a 24% reduction in drug costs compared to fixed-dose regimens.5
In addition to the strategies mentioned above, other programs, such as clinical pathways, claim processing (frequency and amount), indication-based dosing, case management and dose optimization, help control the rising costs associated with specialty medical drugs.
However, with all of these strategies, it is imperative to balance the member access experience with any limiting cost containment strategies. Periodic evaluation of usage management strategies is necessary.
Metrics such as member/supplier disruption, savings, safety and efficacy should be evaluated to ensure these strategies are implemented thoughtfully. Specialist medical drugs play a vital role in improving outcomes.
While cost containment strategies are necessary, it is also important to identify opportunities to optimize outcomes as patients undergo these therapies. Therefore, case management programs or high-touch care delivered by pharmacists are other critical components in the management of specialty medical drugs.
- Tichy EM, Hoffman JM, Suda KJ, et al. National trends in prescription drug spending and forecasts for 2022. Am J Health System Pharm. 2022;79(14)::1158-1172. doi:10.1093/ajhp/zxac102
- Fronstin P, Roebuck MC. Location, location, location: Spending differences for outpatient medication administered by a doctor per treatment location. EBRI Issue Letter. Accessed from https://www.ebri.org/docs/default-source/ebri-issue-brief/ebri_ib_536_locationx3-19aug21.pdf?sfvrsn=cf6c3b2f_4
- Bach PB, Conti RM, Muller RJ, Schnorr GC, Saltz LB. Overspending caused by oversized single-dose vials of cancer drugs. BMJ. 2016;352:i788. Published on February 29, 2016 doi:10.1136/bmj.i788
- Shah V, Spence A, Bartels T, Betcher J, Soefje S. Reducing drug waste, reducing drug costs, and improving workflow efficiency through the implementation of automated chemotherapy dose completion rules in the electronic patient record system. Am J Health System Pharm. 2022;79(8):676-682. doi:10.1093/ajhp/zxab479
- Goldstein DA, Gordon N, Davidescu M, et al. A pharmacoeconomic analysis of personalized dosage versus fixed dosage of pembrolizumab in first-line PD-L1-positive non-small cell lung cancer. J Natl Cancer Institute. 2017;109(11):10.1093/jnci/djx063. doi:10.1093/jnci/djx063