Innovation, Not Piecemeal Efforts, Is the Way to Tame the Specialty Drug Spend, Says OptumRx Exec

New, expensive specialty drugs have proliferated. But what also has increased are the challenges payers face in managing specialty cost trends along with the impact on patients and providers, said Kerri Tanner, RPh, Pharm.D., Optum’s senior vice president for specialty product, during her presentation this morning on the first day of the 2021 Pharmacy Benefit Management Institute® Annual National Conference in Orlando, Florida.

Tanner compared specialty drug management to a Jenga game with analytics at the bottom. Some new entrants in the market are pulling out different elements and may do it well but are not mindful of the whole, Tanner said. By taking a broader approach, Optum's efforts at managing specialty drug costs yield a saving of $16 per member, per month, she said.

Solutions that claim to address specialty spend have flourished, but not all approaches are the same. Although most solutions can help manage one or more aspects of specialty therapies, few address all the key challenges or simplify specialty management for multiple stakeholders.

“Payers need comprehensive, innovative solutions that go beyond traditional medical management and integrate with pharmacy cost-management levers,” Tanner said. She mentioned Optum's analytics that cover both the medical and pharmacy benefits and allow clients to compare how well they are managing spending on specialty drugs and related care. Tanner described an effort at Optum that she is leading to pull together the different services, efforts, and data at the company related to specialty pharmacy. A company model showed that the centralized, coordinated system, dubbed Optum Specialty Fusion, could save Optum clients $15 per member, per month in specialty drug spend.

Specialty medications are now half of the medication spending. Tanner said she often hears from healthcare professionals that their top concern is the rising cost of patient care.

“Most specialty patients see five or more providers and take 10 or more drugs that span both traditional and specialty medications,” she said. “Every specialty patient deserves a personalized health experience supported by clinicians, data and technology whenever they need it.”

These factors, plus the volume of new specialty drugs, make it difficult for providers to keep up with the best treatment options and nearly impossible for plan sponsors to control costs.

“Since specialty treatments can be covered across both the medical and pharmacy benefit, they bring additional complexity, health risk and cost to clinical decision-making,” Tanner said.

Tanner detailed how keeping up with the innovation in the specialty space requires industry-leading clinicians, aggressive analytics and technology.

“The management of specialty medications cannot be delivered in pieces, and we need to support clients in bringing components together to deliver more value,” Tanner said. “Optum sees an opportunity to deliver on this higher value when we combine our medical and pharmacy strategies together.”

Additionally, a solution must solve the current fragmentation, Tanner said. “It must solve it for our payers, our providers and our patients,” she noted.

“Optum has seen success when clients implement a multipronged approach for managing specialty medications,” Tanner said. “This starts with a foundation of excellence that allows us to manage specialty medication costs in three ways: pharmacy benefit management, medical benefit management and connected providers.”

“Keeping up with innovation in specialty requires organization of industry-leading clinicians, analytics and technology with the aim to reduce fragmentation and maintain high-quality care from an integrated benefit management system that is experienced in complex conditions,” Tanner concluded.

Tanner spoke of the "ridiculously large technology" group at OptumRx working on specialty drug management. But she also forecast a future of management not just of drugs but of therapies.

Tanner also discussed United Health Group's pivot to the response to the COVID-19 pandemic ion 2020. The company's call center nurses who normally handle prior authorization calls were reassigned to answer 911 calls for the New York City fire department.

Editor's note: Video was recorded prior to the meeting.