Frequently, trends seen in the group health insurance market eventually trickle their way into the workers’ compensation industry. In most situations, whether these trends involve new treatments, new guidelines or new medications they likely will have an effect on a patient’s overall treatment regimen. Adding to the complexity, however, is often trends begin to emerge in group health before significant data is available to suggest a similar trend in the treatment of injured workers.
A timely and relevant example of this situation can be seen in the growth of specialty medication. In group health, specialty medication use is expected to increase, with an anticipated 30 percent increase in spending over the next five years1. Drivers of this trend will continue to be multifactorial: increased utilization, price inflation and the implosion of the pipeline for new medications.
According to Silvia Sacalis, PharmD, vice president of Clinical Services at Healthesystems, “Specialty pharmacy is a key cost driver in group health, and we are beginning to see growth in utilization of these types of treatment regimens in workers’ compensation. “
Specialty medications are typically expensive and may require special handling, distribution, administration and patient management. They are used to treat complex conditions such as cancer, hepatitis C, HIV, rheumatoid arthritis and multiple sclerosis. Medications include oral, injectable and biologic products. Notably, interferon-free medications such as Gilead’s recently-approved Sovaldi™ (sofosbuvir) — which targets all six hepatitis C genotypes — is projected to become a mainstay of interferon-free hepatitis C treatment regimen. Benefits associated with Sovaldi include shorter duration of treatment, a decrease in severe side effects such as flu-like symptoms and anemia, and a higher cure rate. Wholesale cost of Sovaldi, would be $28,000 for four weeks — or $1,000 per daily pill. That translates to $84,000 for the 12 weeks of treatment recommended for most patients, and $168,000 for the 24 weeks needed for a hard-to-treat strain of the virus2.
Specialty pharmacy is starting to have a significant impact on workers’ compensation. Specialty conditions can either be directly or indirectly related to an injury. Examples of directly related conditions include HIV and hepatitis C resulting from a needle stick or exposure for healthcare and emergency services workers. Alternatively, an injured worker may sustain an injury that can indirectly aggravate existing inflammatory conditions such as rheumatoid arthritis or multiple sclerosis.
The Medication Pipeline
Currently there are more than 5,000 new medications in the drug pipeline globally, and 70 percent of those are potential first-in-class medicines – those that use a different mechanism of action from any other already approved medicine3. Many of these first-in-class medicines will be considered specialty medications once they complete phase III approval by the FDA. For several years, the pipeline for specialty medications has been far more robust than that for non-specialty medications. Specialty pharmaceuticals account for more than half the medications in late-stage development and three quarters of applications for supplemental indications. During the last two years, FDA approvals of specialty pharmaceuticals have outnumbered those for traditional medications. Advances in medicine and better understanding of disease mechanisms have led to an increase in pharmaceuticals.
Workers’ compensation pharmacy benefit managers (PBMs) and payers need to proactively monitor the medication pipeline to prepare for new specialty medications which may be prescribed to treat injured workers. Evidence-based medicine and treatment guidelines will provide insight into appropriate management of these complex conditions.
The number of approvals , as well as the types of specialty products being approved are offering to address many unmet needs for patients that are either non-responsive to existing treatment therapies, or for those patients with conditions for which there were no treatment options in the past. A “personalized medicine approach” is being taken by some pharmaceutical manufacturers, with medications being developed to treat individual patients. Only a handful of personalized medications have been approved in the past decade, however this untapped area is beginning to gain traction. While the potential benefits to the patient are numerous, a close eye should be kept on this emerging pharmaceutical trend.
Specialty medications have made their way into the workers’ compensation system and payers will need to address this new area. Cost containment will be a priority for payers, as these medications can top several hundred thousand dollars annually for a single patient4.
The potential benefits resulting from these treatment options can be great, but so is the cost associated with them. With workers’ compensation payers bearing the full cost of each prescription, it is imperative to get ahead of the cost curve and make informed decisions about these medications. Pharmacy benefit managers such as Healthesystems actively monitor and manage specialty medications as part of a proactive clinical strategy.
A Patient-centered and Holistic Approach
To address the high cost of these therapies and manage patients appropriately, specialty pharmacy solutions need to be patient-centric. Optimal patient therapy management must be holistic, addressing both the primary specialty condition(s) as well as any comorbid condition(s). Support should be targeted toward adverse events and side effects management, as well as compliance, to prevent costly hospitalizations and ER visits.
The most appropriate perspective takes into consideration the overall patient experience: a life-altering diagnosis, multitude of providers to work with, disconnected interactions, and limited networks of providers. The key to success is helping the patient navigate this complex model. All parties involved in a workers’ compensation claim – the employer, the payer, the physician, the claims professional and the PBM – play an integral role in this success.
Innovation in the specialty pharmacy industry and the enablement of technology will change the way healthcare is delivered. As new sophisticated treatment options are approved, specialty pharmacy will continue to grow in importance and size, leading to double digit growth trends.
According to Dr. Sacalis, “Payers cannot afford to ignore this rapidly evolving trend. They must address rising costs and utilization by proactively partnering with their PBM to adopt integrated, patient-centric solutions and strategies that improve outcomes.”
About Silvia Sacalis
Silvia Sacalis, PharmD, is a pharmacist and vice president of Clinical Services at Healthesystems, a leading PBM and ancillary medical benefits manager serving workers’ compensation payers. Dr. Sacalis is a nationally recognized thought leader with extensive experience developing technology-enabled clinical solutions that achieve reductions in pharmacy spend and promote improved patient outcomes for PBMs, payers, health systems, employers and TPAs.
Download our infographic, Specialty Pharmacy Streams into Workers’ Comp, to learn more about how specialty medications are making their way into the workers’ compensation system.
This is a sponsored post from WorkCompWire marketing partner Healthesystems.
1IMS Institute for Healthcare Informatics report, The Global Use of Medicines: Outlook through 2017. Available here.
2FDA Approves Pill to Treat Hepatitis C. Available here.
3Pharmaceutical Research and Manufacturers of America. The biopharmaceutical pipeline: evolving science, hope for patients. January 2013. Available here.
4Rockoff JD. Drug makers see profit potential in rare diseases. Wall Street Journal. January 30, 2013. Available here.