By Silvia Sacalis, PharmD, Vice President of Clinical Services, Healthesystems
Many important pharmacy trends in workers’ compensation usually start from modest beginnings. The key is having the foresight, data and strategies to plan ahead. Spending on specialty medications is expected to increase 30 percent over the next five years as new, innovative products enter the market1. Payers will need to proactively partner with clinical experts to develop strategies to manage this growing trend. A balanced approach focused on managing patient care and improving quality outcomes with cost containment is recommended.
Specialty pharmaceuticals are used to treat complex conditions and include self-administered agents as well as products administered in a physician’s office, the hospital or in the patient’s home. This area of drug development began gaining visibility in the group health care market several years ago. It has grown to represent 15-20 percent of the group health drug spend. As a clinician focused on designing and managing pharmacy programs involving complex medical conditions, I experienced first-hand the evolving growth and significant impact of specialty drugs.
Today, while lagging behind the group health market, this trend is becoming more apparent in workers’ compensation. Based on the results from ongoing analysis of workers’ compensation pharmacy data, the specialty drug prescribing trend is increasingly growing to treat a number of work-related conditions.
The Abundant Medication Pipeline
The upward trend in use of specialty medications will continue as more unique specialty drugs are launched. Pharmacy benefit managers (PBMs) and payers will need to closely monitor the medication pipeline so they can prepare properly for the increased approval of these products. Consider the statistics – the FDA’s approval of specialty pharmaceuticals outnumbered those for traditional medications in the last two years. Currently, more than 5,000 new medications are in the global drug pipeline.2 Many of these medications will be used to treat serious and challenging conditions affecting patients. In fact, specialty pharmaceuticals account for more than half of the medications currently in late-stage development; over a third are biological products.3 Based on the pharmaceutical industry’s focus on developing these new drugs, the expectation is to continue seeing these treatments reflected in workers’ compensation.
Complex Conditions in Workers’ Compensation
Currently, specialty drugs are prescribed to treat conditions either directly or indirectly related to workplace injuries or illnesses — of these, work-related cancers top the list. The CDC reports that four percent of cancer deaths in the U.S. are thought to result from work-related exposure.4 Other directly related conditions — such as HIV and hepatitis — may occur when individuals working in healthcare or emergency services settings are exposed to contaminated material.
Indirectly related conditions — such as inflammatory arthritis — are common, and the subsequent work disability and/or potential of being linked to this group of illnesses is significant. Work disability associated with inflammatory arthritis accounts for the majority of the costs associated with these conditions.5 Other indirectly related conditions that could potentially be compensable in workers’ compensation are those aggravated by a workplace injury, including multiple sclerosis (MS).
Balancing Quality Care and Rising Costs
Evidence-based medicine and treatment guidelines will provide insight into appropriate management of these complex conditions. The potential benefits offered by specialty drugs should be considered in concert with their costs. In some cases, specialty drugs can provide significant benefits since they may offer the only effective treatment available. In other cases, less expensive but equally effective alternative therapies may offer a better choice.
Much has been written about the estimated $84,000 – $168,000 cost of a SolvaldiTM treatment regimen for hepatitis C. The potential to save a life or avoid a costly liver transplant provides a new perspective with regard to cost.
Consider that rheumatoid arthritis (RA) treatment with biologic agents such as Humira®, Enbrel® and Remicade® are often inappropriate and can result in additional unnecessary monthly costs in excess of $2,000.6 However, when used appropriately, these agents may help achieve earlier disease remission. This is imperative as research shows a disproportionate amount of work-related disability occurs early in the RA disease process.7,8 Therefore, the appropriate use of these agents may improve a patient’s ability to perform his or her job and reduce lost time.8 A thoughtful approach is crucial to ensure a correct balance is achieved between improvement in patient outcomes and cost containment.
Cost Influencers and Monitoring Challenges
When analyzing data, specialty drugs can be seen in pharmacy drug benefit data, and physician or hospital bill data — sometimes both. Administration of certain self-injectable biologic agents by rheumatologists in their office can increase payer costs and often are billed as part of a physician or hospital bill. This makes it more challenging for payers to manage utilization, as they may not have full visibility into a patient’s detailed drug regimen.
In some cases, physician dispensing of specialty drugs may occasionally be appropriate for certain office-administered agents; however, it is recommended that self-injectable specialty products be managed through the PBM. This will provide insight and transparency into utilization and cost, and help payers more effectively manage specialty products.
A Growing Concern That Requires a Thoughtful Approach
Specialty medications will continue to grow in importance and pose various challenges for all stakeholders. This rapidly emerging trend requires a thoughtful, patient-centric strategic approach. Employers, payers, physicians, claims professionals and PBMs can work together to effectively manage these drugs and achieve favorable outcomes. Enhancing and expanding existing drug benefit management tools are key building blocks for managing specialty drugs. This includes optimizing drug formulary design as well as incorporating step therapy strategies and medication adherence monitoring tools. Similar to managing any complex medical care for injured workers, improving quality of care and reducing overall costs is best achieved through a comprehensive and collaborative approach.
About Dr. Silvia Sacalis
Silvia Sacalis, PharmD, provides clinical leadership as Vice President of Clinical Services at Healthesystems. Her experience and clinical expertise span the PBM, retail pharmacy and managed care environments. Leveraging her technology background, clinical skills and management expertise, she helps develop and operationalize strategic clinical initiatives to help workers’ compensation insurance payers maximize the impact of a pharmacy benefit management program. Throughout her career, she has held various leadership roles in which she provided oversight of the development of clinical services programs, and integration of analytics technology with clinical consultative support. Dr. Sacalis received her Bachelor of Science in Computer Science and Doctorate of Pharmacy degrees from the University of Illinois at Chicago.
About Healthesystems
Healthesystems is a specialty provider of innovative medical cost management solutions for the workers’ compensation industry. The company’s comprehensive product portfolio includes a leading pharmacy benefit management (PBM) program, expert clinical review services, and a revolutionary ancillary benefits management (ABM) solution for prospectively managing ancillary medical services such as durable medical equipment (DME), home health, transportation and translation services. By leveraging innovation, powerful technology, clinical expertise and enhanced workflow automation tools, Healthesystems provides clients with flexible programs that reduce the total cost of medical care while increasing the quality of care for injured workers. To learn more about Healthesystems or to sign up for newsletters, visit www.healthesystems.com or email info@healthesystems.com.
Notes
1 IMS Institute for Healthcare Informatics. The Global Use of Medicines: Outlook through 2017. Available here (PDF). Accessed February 28, 2014.
2 Pharma. The Biopharmaceutical Pipeline: Evolving Science, Hope for Patients. http://www.phrma.org/sites/default/files/2435/phrmapipelinereportfinal11713.pdf. Published January 17, 2013. Accessed February 28, 2014.
3 IMS Report Predicts Increased Spending on SpecialtyDrugs. Specialty Pharmacy Times, www.specialtypharmacytimes.com/news/IMS-Report-Predicts-Increased-Spending-on-Specialty-Drugs
4 Centers for Disease Control and Prevention. Work-Related Cancer. http://www.cdc.gov/niosh/docs/2010-145/pdfs/2010-145.pdf. Updated May 2010. Accessed February 25, 2014.
5 Shanahan M, Ahern M. Inflammatory arthritis and work disability: what is the role of occupational medicine? Occup Med (Lond). 2008;58:2–4.
6 Demaria L, Acelajado MC, Luck J, et al. Variations and practice in the care of patients with rheumatoid arthritis: quality and cost of care. J Clin Rheumatol. 2014;20(2):79-86.
7 Combe B, Logeart I, Belkacemi MC, et al. Comparison of the long-term outcome for patients with rheumatoid arthritis with persistent moderate disease activity or disease remission during the first year after diagnosis: data from the ESPOIR cohort. Ann Rheum Dis. 2014; doi: 10.1136/annrheumdis-2013-204178. [Epub ahead of print].
8 Furuya H, Kasama T, Isozaki T. Effect of TNF antagonists on the productivity of daily work of patients with rheumatoid arthritis. J Multidiscip Healthc. 2013;6:25-30.
Disclosure:
Healthesystems is a WorkCompWire ad partner.
This is not a paid placement.