The year 2020 holds many exciting changes in the ever-evolving world of managed care. Experts say that organizations can expect to see the launch of new therapies and the payer-related nuances—a direct reflection of the continued push toward personalized medicine.
“We are living through an era of exponential change,” observes Ross Hoffman, MD, chief medical officer at Envolve Pharmacy Solutions.
These changes will impact several areas across a variety of therapeutic areas while driving formulary changes and new payment considerations.
Specialty Drugs and Drugs for Rare Diseases Abound
New specialty drugs emerging from the pipeline will enter the market at an accelerating pace. According to Melissa Duke, PharmD, executive director of population health pharmacy solutions at Banner Health in Phoenix, Arizona, this forthcoming trend will have a significant impact on the managed care industry while altering the patient experience.
"Payers who support these industries are experiencing unprecedented growth—especially with rare diseases and orphan drugs," Duke observes. "These new drugs for rare diseases are life extending and improve quality of life in patients who previously didn't have a therapy available to them.”
Related: 8 Policy Changes to Expect in 2020
More specifically, therapeutic categories with new products on the horizon include gene replacement therapy, gene editing, cell therapy, and cancer immunotherapy—significant industry disruptors that Hoffman says will only help enhance the industry-wide progression to more individualized therapy.
However, the benefits do not come risk free. Many of these drugs are first-in-class with never-before-seen mechanisms of action, unique drug development processes, and special supply chain considerations. And the novel breakthroughs often come at a steep price, with the cost of some of these drugs exceeding $1 million per dose.
Additionally, Sheila Arquette, RPh, executive director at the National Association of Specialty Pharmacy, points out that patients will continue to face challenges accessing specialty drugs, a direct consequence of health plans and payers continuing to limit access to participation in certain networks. Pharmacy carve-outs and channels, or carve-ins, only add to this problem.
The result leaves patients dealing with the fallout—many of whom find the degree of autonomy in selecting pharmacies increasingly more limited. Hoffman believes the price points associated with specialty therapies carry transformative potential while leaving some controversy surrounding unanswered questions regarding the long-term value of these novel drugs.
“We’re seeing accelerated FDA approvals of breakthrough status agents, with only partial evidence of long-term treatment efficacy or durability,” he notes.