How to overcome it
One place health systems can turn to for inspiration around managing drug costs is large employer health plans. Many employers are doubling down on tools and tactics such as prescription quantity limits and stronger care management that ensure the right people get the most appropriate treatment, in the most appropriate setting, and that they adhere to it, says Benjamin Isgur, director, Health Research Institute, PwC, which analyzes trends affecting health-related industries.
Plans are even revisiting traditional strategies, such as requiring prior authorizations for specialty drugs; instituting step therapies, which require patients to try a less expensive drug before “stepping up” to a more expensive option; and limiting the number of drugs in an initial prescription to cut down on waste.
In addition, employers are working with plans to try to shift care to lower cost settings. One way to do this is by offering incentives in plan designs, such as gift cards or other types of payments or savings to steer volume. Treatments that require the help of medical personnel can be less expensive when administered outside of the hospital, Isgur says.
Employers should evaluate and address specialty drug cost and utilization performance through both their medical and pharmacy plans, advises Nadina J. Rosier, PharmD, health and group benefits practice leader, pharmacy, Willis Towers Watson. Moreover, they can implement more aggressive coverage changes and financial incentives to influence sites of care for specialty pharmacy through a medical benefit plan design. “As biosimilars become available, it is especially important to determine what health plans and pharmacy benefit managers are doing to promote them as clinically viable and low net cost options,” she says.
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.