Benefits Canada’s 2015 Pharmacy Solutions In Drug Plan management wrapped up with a five-member panel that considered the future of drug benefits. As specialty drugs continue to grow their share of the market, it may be safe to assume that “new drugs aren’t simply going to be added to formularies, whether they’re specialty or otherwise,” said Neil Donald, director, private payers, at McKesson. He also suggested a “fundamental shift” in approach, with the emphasis on insurance. “Whether through high deductibles or plans specific to higher-cost drugs, coverage may be for catastrophic drugs or drugs that exceed a specific threshold.”
All panellists agreed that specialty drugs are starting to drive changes based on outcomes. “We talk about the right drug at the right price, while the piece we really need to focus on is the right health outcome for the patient,” said Jane Farnham, strategic health solutions leader, with BioScript Solutions.
“Health case management and adherence monitoring have been in place for three years now for patients using specialty pharmaceuticals, and we’re seeing the positive impact on specialty spend. This is really where we have to go to give employers an ROI—and not just for specialty drugs,” noted Kevin West, vice-president of HealthForward Inc. Case management can be applied to disease states such as diabetes, hypertension, mental health and pain management.
Prior authorizations help set the stage at the prescribing level. “Doctors may prescribe what’s familiar to them when clinical guidelines suggest a different treatment be tried first,” explained Barbara Martinez, practice leader, drug benefits solutions, with Great-West Life. When health case management comes into play, “carriers work directly with physicians to ensure prescribing aligns with clinical protocols and criteria.”
While moving toward such an outcomes-based model, plan sponsors can also revisit existing design options to manage costs today. “What’s essentially happening is death by paper cuts—plan sponsors are putting in just one rule or program when they need multiple programs that work in synergy,” said Kevin Wong, manager of pharmacy services at TELUS Health. “[For example], we’ve found some plans that have extraordinary costs for single-source medications. Mandatory generics don’t apply in those cases. There are additional programs that are beneficial in the long run in terms of managing costs.”
All the articles from the event can be found in our special section: 2015 Pharmacy Solutions in Drug Plan Management Conference Coverage.
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