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Claim Analysis By Specialty Pharmacist Saves Health Plan $2.7 Million, Study Finds


A new study highlights the role a qualified specialty pharmacist can play in driving down costs across a health plan.

Employing a single specialty pharmacist dedicated to reviewing specialty drug utilization across a healthcare plan can save millions of dollars, according to a new study.

The data come as high-cost biologics continue to become a larger percentage of the pharmaceutical expenditures. The study results suggest that a proactive approach to managing specialty prescriptions might pay for itself and reduce the overall burden of biologics on the healthcare system.

Co-author Patrick Gleason, Pharm.D., assistant vice president of health outcomes at Prime Therapeutics, said his company has used this model of pairing specialty pharmacists with health plans for a number of years, though he said he is not aware of other programs in which a specialty pharmacist works with health plans that have pharmacy benefit managers and medical claims access.

He said a similar Prime Therapeutics program conducted with Florida Blue in 2107 had a return-on-investment ratio of 10 to 1.

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In the new study, Prime partnered with Blue Cross Blue Shield Alabama to give a specialty pharmacist access to integrated medical and pharmacy claims data, as well as prior authorization for the plan’s 1.5 million members. Working alongside the Alabama Blues plan’s pharmacy department, the specialty pharmacist looked for opportunities to save money using methods such as changing prior authorization processes; recovering fraud, waste, and abuse (FWA); and changing patient dosing or therapies.

The results were scheduled to be presented at the Academy of Managed Care Pharmacy’s 2020 meeting, but the in-person event was canceled because COVID-19. Online presentations and abstracts replaced the meeting.

What Gleason and colleagues found was that the single specialty pharmacist was able to save the plan a total of $2.7 million. Those savings were the result of many changes, but the bulk of the savings came from just a few small decisions.

For example, the pharmacist recommended improving the prior approval process for patients with hepatitis C so that only 56 days of therapy was dispensed; the plan saved more than $1 million as a result.  Reductions in FWA led to nearly $700,000 in savings. Dosing optimization for nine members taking secukinumab (Cosentyx) resulted in $328,000 in savings and $31,000 for a single patient taking ibrutinib (Imbruvica).

Gleason said FWA is a perennial problem, though it varies somewhat depending on the drug class or program.

“We have an extremely robust FWA program, so we expect that to squeeze savings out to its maximum potential, and that’s what we saw here as well,” he told Managed Healthcare Executive.®

One of the biggest chunks of savings in the study came from a single patient who was over-using acute treatments for hereditary angioedema (HAE). Provider intervention in that case resulted in $462,285 in savings.

Gleason said such “super-spenders” - those with annual expenses exceeding $250,000 - are uncommon, but their numbers are increasing “at an alarming rate.” He noted that previous research from the company found that the number of super-spenders increased by 60% from 2016-2018, accounting for 8.6% of total drug spend in the study.

“Finding outliers such as that one acute HAE member is exactly why having specialty drug pharmacists with comprehensive access to health plan and PBM data and service offerings are so valuable,” he said.

Gleason noted that prior authorizations are decisions made at a single point in time, and thus the appropriateness of the therapies can change, too. “Medication regimens may change over time and inappropriate therapy may occur,” he said. “It is with a dedicated pharmacist eye - like in this managed care pharmacist program- where we can find these needles in haystacks that are driving up costs.”

The study is titled, “Specialty Drug Managed Care Pharmacist Clinical Review Program Savings Among 1.5 Million Commercially Insured Lives.” The abstract can be found on the AMCP website.

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