Real-World Perspectives in Biologics/Specialty Drug Use Costs

There is significant interest among employers and other health care stakeholders in understanding the extent, scope and management of biologics/specialty drug use in covered populations due to its high cost impact.  Most presentations, discussions and articles on this topic area have either been market survey results or PBM marketing of their specialty pharmacy programs.  What has been missing is objective learning from a real-world perspective and establishing a baseline for commercial plan sponsors that could result in actuarial based change in benefit design focusing on optimal patient outcomes.

The Midwest Business Group on Health’s (MBGH) work in examining the value-based purchasing activities of employers has identified the biologics/specialty area as a major challenge and focus for employers.  Along with the higher cost of these medications that are increasingly being produced for a rising number of conditions, comes increasing waste from inappropriate prescribing by physicians, non-compliance by patients, and potentially serious side effects.  Biologics/specialty has also become the key area of research and growth for manufacturers.

Although some efforts have been developed for biologics/specialty, most do not explore the topic areas this project seeks to target. In this initiative, we will enhance the plan-sponsor’s awareness, education and optional approaches in managing this area. Our goal is to extend and expand the knowledge to enable employers to be proactive with their vendors as well as to address how vendors in the marketplace can better meet their customers’ needs.

In developing an initiative to assist employers and others to address the challenges of biologics, a review of current vendor activities with clients needs to be conducted, as well as a literature search to avoid producing materials or studies that have already been covered. Currently, PBM and health plan activity has been basic and cost focused with outshoots of specialty drug management change tested by a very select few.

Due to the uncertainty and challenges that health reform is also placing on employers, health plans and PBMs, scant innovative resources are being focused on biologics benefit innovation. Subsequently, there is a valuable opportunity for this type of project that can provide a clearer vision of the barriers today with an eye towards more effective coverage strategies in the future.