By Jeremy Schafer, Precision for Value
Costs of infused drugs are growing and attracting the attention of payers, providers, and the government. The primary reason for the increase is the rising cost and utilization of infused specialty medications. According to Magellan, the five-year trend of specialty drugs on the medical benefit is 68 percent in commercial plans, with a double-digit growth year over year. Medicare, while experiencing slower growth, is rising as well.1 The growing cost is forcing payers to turn their attention to medical benefit drug management despite the complexities in understanding the data, navigating a myriad of reimbursement schemes, and keeping provider networks satisfied. An emerging target for payers in the infused drug space is how IV drugs are distributed to providers and where these products are administered. Site of care strategies can generate cost savings, but they may also create unintended consequences as new controls disrupt the traditional dynamics of buy and bill. However, just as biosimilars have disrupted the status quo of the biologics market, they may also find opportunity in impacting how care is delivered.
Why Does Site Of Care Matter?
Where an IV drug is administered has an impact on cost. A study conducted by the EBRI Center for Research on Health Benefits Innovation analyzed the difference in cost of the top 37 infused oncology drugs when administered in clinics versus hospital outpatient departments (HOPDs). Approximately 1.7 million members under age 65 included in the 2016 MarketScan Commercial Claims and Encounters database were studied. The study found that hospital prices for the studied drugs averaged 86.2 percent more per unit than when the same drugs were administered in clinics. The mean annual reimbursement per user was $13,128 in physician offices compared with $21,881 in hospitals. The authors stated that employers would save approximately 45 percent if all the medications in the study were reimbursed at clinic prices.2 Higher cost for HOPD versus clinic or home has been found in other therapeutic categories as well, including hemophilia factor, autoimmune biologics, and infused immunoglobulins.3
Payers are taking action on site of care. BlueCross BlueShield of Tennessee (BCBST) has drawn the ire of multiple medical societies due to the planned launch of a new management program on July 1, 2020.4 The BCBST program would require prescribers of medications on BCBST’s specialty medication list to obtain these products via a pharmacy in BCBST’s specialty pharmacy network.5 The BCBST specialty medication list includes an array of infused biologic therapies across cancer, autoimmune, macular degeneration, and other categories.6 The goal is to consolidate purchasing to drive down costs while at the same time eliminating the traditional upcharge associated with buy and bill. UnitedHealthcare has been active in the site of care space as well by implementing a policy that requires patients to receive certain infused drugs in the clinic or home versus at the HOPD if it is safe to do so. UnitedHealthcare’s Optum claims savings as high as 90 percent per day when medication is administered in the alternate site of care versus HOPD.7
Possible Gaps In Site Of Care
Shifts in site of care treatment and product distribution may bring new stakeholders into the picture. Specialty pharmacies, an integral component of BCBST’s program, have significant experience in dispensing self-administered (oral, SQ injection) products directly to patients. However, the experience in IV products may vary both on a broad level and between different categories. Specialty pharmacies are accustomed to working with IV immunoglobulin and hemophilia, but may be breaking new ground if asked to dispense infused oncology products. In addition, the dispensing of product to a provider or provider office may add new complexities to which specialty pharmacies are not accustomed.
Access to care may be an issue as well. Payer management that requires patients to receive home therapy or avoid HOPD may require patients to engage new stakeholders or travel farther distances. While payer policies may provide exceptions for undue patient burdens, there is still the potential that the change in site of care may complicate the patient’s status quo, which may lead to noncompliance.
Opportunity For Biosimilars
Biosimilars produce the same clinical results as their brand counterparts. Where biosimilars can differentiate are price and services provided to healthcare stakeholders. The emergence of site of care management represents a shift in stakeholders that may create opportunities for biosimilar manufacturers. Specialty pharmacies with a growing role in infused products would benefit from manufacturer partnerships in the areas of patient education/counseling, product storage guidance, and training on product safety and clinical data. These needs may be particularly acute in the infused oncology space where many specialty pharmacies have had minimal exposure. Biosimilar manufacturers can take a lead by engaging specialty pharmacy stakeholders to not only build partnerships, but also gain a competitive edge over other products. However, the specialty pharmacy engagement should not come at the expense of the traditional channels like clinic and HOPD business, which will still represent the significant majority of infused product sales for the foreseeable future.
Biosimilar manufacturers, especially those of oncology products, may also benefit from conducting studies on the safety of their products when used in the home. As home care services have evolved, patients are increasingly able to be treated in the home environment safely, while also saving on cost and increasing patient satisfaction.7 Studies in the safety of administering IV products in the home could generate important evidence that could expand care in the home space. Not only would this allow patients more flexibility in where care is received, but it would also give providers more options, particularly for patients with limited access to healthcare facilities. Biosimilar manufacturers could also provide resources to patients, home infusion providers, and prescribers through programs that can assist patients with transportation to different sites of care for treatment.
Where patients receive care is evolving. Part of this evolution is payer driven as a way to save costs, but another part is due to the emergence of more options in home care and an improving safety profile of therapeutics. Biosimilar manufacturers seeking to differentiate themselves from competitors may find opportunities with stakeholders involved in alternate sites of care. Doing so may reduce costs while keeping care the same, a mantra of biosimilars. As the market evolves, biosimilars should be on the leading edge, before brand competitors beat them to the punch.
- Managed Healthcare Executive. The forces driving specialty drug spending. https://www.managedhealthcareexecutive.com/article/forces-driving-specialty-drug-spending. April 2, 2019. Accessed February 19, 2020.
- EBRI. Cost differences for oncology medicines based on site of treatment. EBRI Issue Brief No. 498. https://www.ebri.org/docs/default-source/ebri-issue-brief/ebri_ib_498_chemocosts-16jan20.pdf?sfvrsn=9d073d2f_4. January 16, 2020. Accessed February 19, 2020.
- Magellan Rx Management. Medical Pharmacy Trend Report: 2018 Ninth Edition. https://www1.magellanrx.com/documents/2019/03/medical-pharmacy-trend-report_2018.pdf. Accessed February 19, 2020.
- Healio. ACR, seven medical societies warn BlueCross BlueShield against new in-office treatment policy. https://www.healio.com/rheumatology/practice-management/news/online/%7B631408ac-4a09-4454-9834-7aa5dbc6c0ba%7D/acr-seven-medical-societies-warn-bluecross-blueshield-against-new-in-office-treatment-policy. February 12, 2020. Accessed February 19, 2020.
- BCBST. Provider administration manual. https://www.bcbst.com/providers/manuals/bcbstPAM.pdf. December2019. Accessed February 19, 2020.
- BCBST. 2020 provider-administered specialty drug list. https://www.bcbst.com/docs/pharmacy/provider-administered-specialty-pharmacy-list.pdf. Accessed February 19, 2020.
- Optum. Home infusion therapy: better outcomes. https://www.optum.com/resources/library/home-infusion.html. Accessed February 19, 2020.
About The Author:
Jeremy Schafer, PharmD, MBA, is senior VP and director of the Access Experience Team at Precision for Value. He provides enterprise leadership across Precision’s Access Experience Team and leads integration with other enterprise teams including health economics outcomes research, provider marketing, access and analytics, and media outreach in the specialty space. He has been involved in projects including payer value proposition development, ICER counter strategy marketing, market research in emerging areas like gene therapy and biosimilars, value assessment, and competitive simulations in oncology and specialty markets.