Value-Based Management of Specialty Drugs: Practical Considerations and Implications for Pharmacy
Not all approaches are suited to meeting policy makers and health plans’ goals of managing specialty drugs based on their value. Researchers conducted a qualitative study with Blue Cross Blue Shield plans interested in implementing value-based specialty pharmacy management to observe the plans’ objectives, strategies, and factors influencing their ability to execute on these strategies.
Specialty pharmacy drugs are the greatest drivers of prescription drug spending in the US. They account for 46.5% of spending on pharmaceuticals despite comprising only 1.9% of prescriptions dispensed.
Because of this, specialty drugs are attractive targets for more active management.
The study used three focus groups with four total business objectives identified. The business objectives centered around spending levels, spending variability, access to new treatments, and evidence generation for new treatments. Factors that influenced their ability to act on the strategies included regional and national scale, the strength of provider network relationships, disease managements capabilities, business and data silos, and potential legislative actions to limit utilization management.
In conclusion, the researchers suggested that plans’ preferences for different forms of specialty pharmacy management may not be aligned with policy objectives, in particular those that advance innovation. Policymakers should consider both limiters and incentives in the market and non-market environments in which plans operate. This includes the need to mitigate spending variability and generate evidence to guide coverage decisions.
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Policy makers and health plans must work to make new treatments available while balancing cost concerns. While there are many approaches to achieving this goal, not all are equally effective.
Due to spending variability, budget constraints, insufficient clinical evidence, competitive pressures, and data and human resource constraints, health plans experience pressure to pursue long-term financing and outcomes-based contracting approaches.
Value-based management of specialty prescription drugs is superior to long-term financing and outcomes-based contracts, but will require policy initiatives that incentivize value-based pricing and insurance design.