The Effect of a Specialized Case Management Program On Factor Replacement Use On Patients with Bleeding Disorders
Authors: Bonagura Anthony , Decristofano Eileen , Faulds Roberta , Rich Keryn M , Schiavone-Grosser Judith , Deniz Carol A , Aledort Louis M. 
Published: October 2019

Abstract
Abstract 4257
Patients with Hemophilia A and B and Von Willebrand Disease have benefitted from improvements in the management of their disease over the past generation, both in terms of quality of life and life expectancy. Since these are chronic conditions they require ongoing management and treatment. This often results in a significant cost. The major contributor to this is the cost of factor replacement, which can be magnified if not handled in the most efficient manner. This pressure exists across the spectrum of medical coverage in the United States from commercial third party payors to Medicaid and even for the uninsured. In response to pressure to contain costs there is an increasing variety of coverage and cost-sharing strategies which may have an unintended effects on the care these patients receive. In response, we report on the financial impact of an intervention by specially trained case managers under close clinical guidance on patients with these diagnoses.

Methods:
A team consisting of a medical director, nurse case managers and an outside advisor with expertise in the field of bleeding disorders evaluated every member of the insurance plan identified with the diagnosis of Hemophilia A, Hemophilia B or Von Willebrand's disease. The evaluation consisted of an assessment of the individual's clinical status related to the diagnosis, complications and co-morbidities. Information on where care was obtained, how often follow up occurred and the specific treatment regimen was collected. Specific attention was paid to the type of replacement product used, the amount and the treatment regimen. The source of replacement therapy was noted (i.e., insurer associated pharmacy, 340B program or commercial pharmacy) and a comparison of costs was performed. Patients were then educated on the differences and given a choice as to where their future pharmaceutical needs would be met. Ultilization was followed for a year and the amount of saving was calculated.

Results:
The result shows the achievement of significant savings through this program, as shown in the table below. These savings were achieved without changing the regimen or any aspect of the treatment plan initiated by the treating team, but by simply offering a more financially beneficial source to supply replacement therapy. In the vast majority of these cases that choice involved using a 340B program when available. The saving tended to be higher among those receiving prophylaxis as those regimens used the most factor replacement.

Conclusion:
With an increase in cost sharing strategies, which will require increased out of pocket expenditures on the part of patients with even the best insurance coverage there is a need to be more cognizant of how health care dollars are spent. This is especially true for those with chronic conditions that are expensive to treat, with these bleeding disorders being a prime example. The 340B programs available throughout the country offer a substantial discount that appears to be sub optimally utilized. Furthermore these programs are often associated with large academic centers that are able to offer these patients the most advanced treatments available.
In our project we have been able to show savings in excess of $1.5 million using a relatively simple intervention. It is worth noting that there were a significant number of members who chose not to make any changes as the choice of participation were solely voluntary. Furthermore there was no attempt to change to a less expensive alternative. The implication is that this represents a simple intervention that can be made in other setting including other commercial plans and national programs and can show a large financial impact for these patients. In addition, this program allows ongoing reevaluation of a patient to respond to changes in an individual's relevant needs.

Disclosures:
Bonagura: Aetna Insurance: Employment. Decristofano:Aetna Insurance: Employment. Faulds:Aetna Insurance: Employment. Rich:Aetna Insurance: Employment. Schiavone-Grosser:Aetna Insurance: Employment. Deniz:Aetna Insurance: Employment. Aledort:Aetna Insurance: Advisor Other.