Payer Perspectives on Balancing Access & Affordability of Specialty Medications in the Evolving US Healthcare System
Creators: name: Muller, Benjamin
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2019

description: Introduction: The rising cost of prescription drugs in the United States has become a concern for patients, prescribers, payers and policy makers. Prescription medications comprise an estimated 10-14% of overall personal health care services in the United States, and drug spending is projected to grow at a faster rate than overall healthcare expenditures in the coming years, comprising an increasingly larger percentage of our nation’s health care expenditure. With the introduction of specialty medications (e.g. direct-acting antivirals for Hepatitis C and oral chemotherapy agents), traditional-cost containment strategies are no longer sufficient, necessitating the use of novel managed care strategies to improve patient outcomes and decrease costs.Methods: A comprehensive literature review was conducted utilizing electronic databases to describe traditional cost-containment strategies and uncover innovative strategies currently being implemented in the Hepatitis C and oral chemotherapy space. Key payer stakeholders (public and private payers, self-funded payers, health systems, integrated delivery networks, and pharmacy benefits managers) were engaged in in-depth, semi-structured interviews to validate the findings of the literature review. Additionally, payers were invited to discuss current and future innovative managed care cost-containment strategies that are being implemented or developed in real-world pharmacy practice.Results: Four categories of managed care clinical programs were identified that have a clear impact on clinical and financial outcomes associated with the management of Hepatitis C and oral chemotherapy products. These strategies include: (1) task-shifting, (2) medication optimization with refill outreach, (3) oral chemotherapy programs, and (4) oncology financial assistance programs. Each type of strategy was examined to describe program impact, application and effectiveness as a managed care solution. These strategies were then validated by key payer stakeholders, uncovering additional cost-saving mechanisms related to: (1) traditional managed care strategies, (2) CMS policies and programs, (3) value-based contracting, (4) pharmacy benefit design, and (5) future cost savings measures under development. These mechanisms were examined to identify health policy recommendations.Conclusions: As the United States moves towards a value-based healthcare system, innovative cost-containment strategies that utilize clinically-oriented, outcomes-based metrics and approaches will increasingly become standard pharmacy practice as physicians strive to maximize value-based reimbursements while payers seek to balance access and affordability. The managed care solutions detailed in this study validate cutting edge pharmacy practice advancements that can improve health outcomes while more effectively controlling overall healthcare expenditures. Healthcare- and formulary-decision makers (as well as policy makers) can use the findings of this study to begin implementing innovative managed care pharmacy practice models and drug utilization review solutions to contain the rising cost of specialty drugs.