From Specialty Pharmacy News

Payers Are Showing Interest in Strategies to Manage Hemophilia

Reprinted from SPECIALTY PHARMACY NEWS, a monthly newsletter designed to help health plans, specialty pharmacies, pharma companies, providers and employers contain costs and improve outcomes related to high-cost specialty products. Subscribe today!

By Angela Maas, Managing Editor
October 2017Volume 14Issue 10

While some specialty drug-treated conditions such as rheumatoid arthritis lend themselves to traditional management tactics, hemophilia requires a more individualized approach, and thus payers have not applied many of those strategies to this category historically. However, some payers now are looking to approaches such as site-of-service management and outcomes-based contracting as potential opportunities. And multiple new therapies for both hemophilia A and B hitting the market, including three in 2016 and one so far in 2017, could make some of these approaches more doable than they might have been before.

The 13th edition of the EMD Serono Specialty Digest, released in May, said that hemophilia was the No. 3 therapeutic category focus for site-of-care strategies, with 61% of respondents citing it. Hemophilia was behind only rheumatoid arthritis/Crohn’s disease and intravenous immune globulin, both at 82%. Results were based on responses from 28 commercial health plans that had at least one site-of-care program.

“For hemophilia, site-of-service management is largely focused on keeping patients out of the emergency room, ensuring patients have the drugs and supplies they need, and ensuring they have the knowledge, training and/or nursing services required to administer treatment at home,” says John Louis, director of category management at Diplomat Specialty Infusion Group.

According to Haita Makanji, Pharm.D., vice president of clinical strategy and programs at Magellan Rx, the PBM unit of Magellan Health, Inc., “even though site of service may remain the same, Magellan Rx has observed vast differences in unit billing rates among unique facilities and even different pharmacies. There is an opportunity for payers to not only do a better job contracting standardized rates, but also encourage utilization of rendering providers with the most cost-effective unit cost.”

Among the 42% of respondents either with an outcomes-based contract in place or planning to implement one within the next 12 months, 8% said they currently have at least one such contract within hemophilia/other bleeding disorders, while 13% said they planned to implement one within the next year.

Specialty Pharmacy News

“Several of the major health plans are requiring specialty pharmacy therapy providers to submit outcomes data regarding patient status,” says Kirstin Schmidt, national clinical director – bleeding disorder program at infusion services provider Option Care, part-owned by Walgreen Co. “The data is based on assay management, ER visits (ER avoidance), bleed rate, factor usage, hospitalizations, outpatient procedures and unscheduled clinic visits.”

“We have not encountered any clinical outcomes–based contracting,” says Louis. “However, there are special circumstances where performance guarantees might include penalties for avoidable emergency room visits (e.g., when a patient cannot treat at home due to an inadequate supply of medication or when a nurse cannot be deployed in time).”

Assay management guarantees, which require that pharmacies “dispense factor within a narrow aggregate variance,” are more common, he says.

Thirty-three percent of respondents said they covered hemophilia factor under the pharmacy benefit only, 48% covered it under the medical benefit only, and 19% covered it under both benefits.

View the EMD Serono report at www.specialtydigest.emdserono.com.


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