Survey: Managing Total of Cost of Care is Top Priority


Specialty medications represent a large and growing proportion of overall drug spend, but plans and employers are struggling to understand their costs to make good decisions, finds the latest PSG Specialty Drug report.

Managing the total cost of care has become a focal point for plans, according to the most recent Trends in Specialty Drug Benefits Report. The latest report from Pharmaceutical Strategies Group (PSG), an EPIC company, finds that specialty medications that treat a broader range of disease states are contributing to a double-digit specialty trend for many payers. Meanwhile, cost savings opportunities such as biosimilars and medical drug rebates have not yet fully materialized as hoped.

Morgan Lee

Morgan Lee

“Respondents’ top goals are managing total cost of care. But on the flip side, one of the highest rated challenges they have is getting access to reliable data on the total cost of care medications,” Morgan Lee, Ph.D., MPH, senior director, Research and Strategy at PSG said in an interview. “They are really struggling to access the data that they need to actually understand the impact to total cost of care and make good decisions in that respect.”

Lee said part of the problem is that specialty drugs are covered both through the medical and the pharmacy, and the data are not integrated. “Getting truly integrated data to look at both sides of where drugs are being covered and understand what’s happening can be a challenge,” she said.

Lee explained that employers’ and plans’ agreements have different levels of reporting and detail. Additionally, plans need the resources to analyze and obtain insight from the data.

The PSG report was by co-sponsored by Genentech, a member of the Roche Group. PSG surveyed 185 pharmacy benefit leaders in September 2023 and October 2023. The respondents represented employers, health plan, and unions. Employers made up the largest portion of the respondents, followed by health respondents. Most of the respondents used one of the three large PBMs — CVS Caremark, Express Scripts or Optum Rx — to administer their prescription drug program.

Beyond assessing the total costs of medications, respondents also said patient affordability of specialty drugs for members was another top concern.

Overall, the respondents said pharmaceutical company copay assistance help patients afford medications. And employers tended to agree copay assistance helps plans save money.

Plans can save money by using copay adjustments programs, such as accumulators maximizers. With accumulators, the money from copay cards does not count toward patients’ annual deductible or out-of-pocket limit. With maximizers, the copay assistance is evenly spread over the year and classify some medications as non-essential, which limits the plan exposure to drug costs.

The PSG survey found that more respondents are using copy accumulator and maximizer programs than last year. In fact, more than half of respondents (53%) using copay accumulator programs, which 45% used copay maximizer or variable copay programs. Within the employer group, smaller employers were less likely than larger employers.

The three large PBMs use accumulator programs. But at the same pharmaceutical companies. Some pharmaceutical companies have begun to lower the total amount of assistance given to patients through copay cards when accumulator or maximizer programs are in effect.

Related: Patients Often Lose in the Battle between Pharma and PBMs

In terms of utilization management programs, the PSG report found that most commonly used program was prior authorization (used by 97% of plans), and the least commonly used program was niche specialty pharmacies for management of certain conditions (used by 27% of plans).

Other: findings from the report include:

  • 93% of those surveyed receive specialty drug rebates under the pharmacy benefit. Receipt of rebates under the medical benefit rose from 39% last year to 44% in this year’s survey, reflecting plans’ efforts to manage the financial impact of specialty drugs.
  • 33% of all respondents cover a Humira biosimilar in a preferred position, and 38% intend to do so.
  • 74% anticipate gene therapy affordability will be a moderate or major challenge for their organization over the next two to three years.
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