New 'playbook' helps employers navigate specialty drug costs


Considering that the annual cost of specialty drugs to treat certain chronic conditions can exceed $100,000, the Minnesota Health Action Group has developed action plans that all stakeholders within the drug delivery chain can take to drive efficiency and transparency in the marketplace.

The group’s Specialty Drug Employer Playbook details what each stakeholder can do to advance the “5 Rights” for employers and consumers—right drug, right price, right place, right support and right data. The framework for the playbook, a cumulative effort by the Action Group’s “Guiding Coalition” of 40 members across the delivery chain, has been adapted by the National Alliance of Healthcare Purchaser Coalitions and is available to member coalitions throughout the country.

The playbook lists four high-level goals that employers should expect for each stakeholder group—health plans, provider organizations, pharmacy benefits managers, specialty pharmacies and manufacturers. These high-level goals are followed by detailed action plans to achieve the goals—and scoring criteria that employers can use to measure how well each stakeholder is performing.

“Inaction is not an option,” says Carolyn Pare, president and CEO of the Minnesota Health Action Group. “For years, employers and consumers have been paying for things we don’t even know we’re paying for. This has to change.”

“With the Playbook, employers will now be better equipped to gain more control over specialty drug use and spend on behalf of their employees, which will ultimately contribute to stabilizing a very broken system,” Pare says.

The four high-level goals for health plans:

  1. Require submission of actual National Drug Codes (NDCs) and Healthcare Common Procedure Coding System (HCPCs), units, quantity and day’s supply by all providers in all settings.
  2.  Contract with providers to assure cost parity of all sites of care for the same drugs and services.
  3. Involve employers in key decisions that affect their overall costs.
  4. Align total cost of care (TCOC) and accountable care organization (ACO) provider contracts so practitioners select and/or administer high-value drugs.

Provider organization goals:

  • Include actual NDCs and HCPCs, units, quantity and day’s supply by all providers in all settings. Use NDCs for prior authorization, utilization management, payment, collection of rebates, claim level reporting, data analysis, provider contracts and patient outcomes.
  •  Include cost parity across all sites of care for the same drugs and services in all contracts.
  • Ensure practitioners better know drug prices (what employers and consumers are paying) at the point of care to support the use of high-value drugs.
  • Align TCOC and ACO provider contracts so practitioners select and/or administer high-value drugs.

Pharmacy benefit manager goals:

  • Accept fiduciary responsibility (ERISA definition).
  • Ensure a level of financial transparency so purchasers know exactly how their money is being spent.
  • Provide claim level reporting, including all data fields, for employer ad hoc analysis.
  • Involve employers in key decisions affecting their overall cost.

Specialty pharmacy goals:

  • Ensure a level of financial transparency for purchasers.
  • Ensure that high-level, timely clinical expertise supports provider decisions to use high-value drugs that the goal of achieving optimal outcomes.
  • Make operational processes and decisions on behalf of the purchaser, independent of the specialty pharmacy parent organization’s financial interests.
  • Provide/improve patient education and support that includes timely instruction on drug administration and emotional/social support to increase adherence and improve outcomes.

Manufacturer goals:

  • Create a model of financial transparency that will assist purchasers in making value-based decisions.
  • Discontinue consumer coupon programs that encourage use of low-value, high-cost drugs in place of therapeutically equivalent generics.
  • Ensure that price increases over time do not exceed the Consumer Price Index (CPI).
  • Develop and implement value-/performance-based pricing.

“Transparency means different things to different people,” Pare says. “And ultimately, we need to push beyond transparency to solutions that ensure employers and individual purchasers have access to the right drug, at the right price, at the right time, in the right setting, and that they have access to the right data.”

Posted 11:00 AM

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