Connected in care: a proactive approach to managing specialty drugs
It’s not news that specialty drugs account for a disproportionately high percentage of overall drug spend. As more of these drugs come to market, it’s increasingly important for payors to have an end-to-end strategy for managing utilization, from the start of therapy and continuing for as long as the member is on the drug, to help promote better health outcomes and control costs.
Specialty medications are used to treat complex medical conditions like hemophilia, autoimmune diseases, cancer, and HIV. While only a small percentage of people rely on them, the impact on spend is remarkable.
1.7%
of members using specialty medication
>53%
of overall drug spend is for specialty medications
Cassandra Ford and Tierra Ford discuss connected specialty care at 2023 Forum
The vast majority of your spend is coming from those members
who are already on their therapy. The other 12% is coming from those new to therapy utilizers. This could be members who are on a specialty medication who are brand new to your plan, or this could be an existing plan member who is starting a specialty medication for the very first time.
It's critical, not just to manage the prior authorization process in the beginning for that 12% of your spend, but managing these patients across the entire course of their therapy, and- of course- their journey, is essential.
We want to start every patient's journey with confidence and certainty. So this is getting your members on the right medication from the very start. We want to eliminate waste throughout the duration of treatment. Whether this is realigning refill dates because we see your members are filling their medications early and they're accumulating additional spend or medication, or if we find them taking a higher dose than needed according to the guidelines.
And then lastly- intervening when needed. If their therapy is ineffective, we don't want them to continue on their therapy. So maybe we need to stop doing therapy. Maybe we need to intervene and get them on a different therapy.
When you have the connections that we do, you're really able to maximize the savings again throughout the entire member journey. Our ability to engage with both the patients as well as their providers all in real time puts us in that best position and gives us those critical opportunities where we can both lower costs as well as improve care for members.
I'm going to walk us through a real life member experience and share with you how our connections were able to work seamlessly to manage complex condition and spend for this client.
I want you to meet Alex. Alex is 19 years old. He was diagnosed with hemophilia when he was just 8 months old, and he started service
with CVS Specialty back in 2019. Understanding how to provide optimal treatment is key in managing costs. In Alex's case, he used his app to refill prescriptions on a monthly basis. And in doing so, we were able to have him answer certain questions, such as:
When was the last dose of factor that he took?
How many vials of factor did he have remaining?
What was his current weight?
Had he had any changes in his activity level?
And that enabled us and our clinical pharmacist on the Hemophilia CareTeam to identify that Alex had experienced a recent change in weight and was getting a little bit more active, which prompted a discussion with Alex's provider to evaluate if it was time to increase or adjust his dose of factor product.
Alex's factor product dosing was increased and what happened next was that the accorded nurse made outreach to Alex and his mom to make sure that they understood the change in that dosing, the increase in the frequency based off of the new prescription, as well as his activity level. And that accorded nurse was also able to provide some additional tips to help Alex manage some of that lifestyle change with his increase-increasing playing basketball over the weekends.
So hopefully through this example, you've been able to see how our connections work to provide comprehensive care management and support for a client and their member.
Prior authorization has long been used to help manage utilization. However, the majority of specialty drug spend occurs beyond the first fill. So, it’s critical to connect with members who use specialty medications, as well as their care teams, throughout the duration of therapy to monitor effectiveness, adherence, and changes in symptoms and health status, so that we can proactively determine when adjustments may need to be made.
98% of specialty spend comes after the first fill
Optimizing connections to optimize outcomes and cost
Given the growing consumer demand for digital connectivity, plan sponsors have a significant opportunity to yield higher value when they work with a PBM partner that proactively uses digital innovation to engage with patients and providers as an integral part of its specialty utilization strategy. This includes connecting electronic health record (EHR) data, real-time benefits visibility plan members and their providers can view at the point of prescribing and beyond, and ongoing touchpoints with patients to monitor how treatment is going.
95%
of CVS Specialty patients have elected to receive digital messaging
Over 80%
of CVS Specialty patient records are available via EHR connectivity
During our 2023 Forum, Cassandra Ford, PharmD, AVP, Clinical Account Services, and Tierra Ford, PharmD, Senior Clinical Advisor of Specialty Client Solutions, talked about what that looks like, including a case study on a hemophilia patient to illustrate how these interventions work in practice.
