The Academy of Managed Care Pharmacy’s 25th Annual Meeting & Expo on April 3-5, 2013, in San Diego attracted double the expected attendance. Why, you may ask? This was the inaugural AMCP/NASP Specialty Pharmacy Conference. Then again on May 6-9, 2013, hundreds of attendees descended on Phoenix for the National Council for Prescription Drug Programs' 2013 Annual Technology & Business Conference.
It should be no surprise to anyone that the three main common themes during these two events were specialty pharma, the rise of the retail pharmacy clinic, and accountable care—and how technology supports these three themes, whether it be from the administrative, financial, or clinical perspectives.
Specialty Drug Spend Expected to Skyrocket: Who Pays the Bill?
Specialty drug spend is expected to remain at double-digit levels through 2014—and Express Scripts projects that spend growth in the segment will hit 67% by 2015. This is a double-edged sword for payers, who must balance the costs and benefits for patients. Rheumatoid arthritis, multiple sclerosis, and cancer account for close to 70% of the total specialty spend. A spate of new specialty drugs posed to enter the market will make this problem even more complex.
Payers and providers need to rethink their wellness strategies and matrixes, as well as the tools that aid in decision-making around delivering evidence-based medicine. Today, some health plans have 50 drugs classified as specialty drugs, and others have 200 drugs classified as specialty drugs. This matters when it comes time to decide who pays the bill.
Some weapons that come to the fore are delivery system changes; payment system changes; mechanisms to aid medical adherence, such as electronic prior drug authorizations (PAs); and innovative benefit design. Interestingly, in a specialty pharma survey conducted by Avalere, provider acceptance was the most common critical success factor for health plans across all activities. And perceptions among pharmacy benefit managers (PBMs), employer coalitions, and self-insured employers were consistent with health plans. They view delivery system changes as an emerging opportunity area. In addition, cost reduction and appropriate utilization are the primary drivers for engagement, similar to national and regional plans.
Can You Say “Biosimilar”?
Today, instead of the iconoclastic word “plastics” in the movie The Graduate, Mr. McGuire would have said, “biosimilars.” The Public Health Act Service Act defines biosimilar or biosimilarity as follows: “The biological product is highly similar to the reference product notwithstanding minor differences in clinically inactive components. There are no clinically meaningful differences between the biological product and the reference product in terms of the safety, purity, and potency of the product.” The prevailing theme is not IF, but WHEN biosimilars will move through process and be available. The key message we heard was biosimilars are not generics. They will involve significant go-to-market costs for a pharmaceutical manufacturer, so they will behave and be marketed more like a traditional new drug launch.
ePA Passed: What This Means to You
The NCPDP’s Work Group 11 (WG11) Prior Authorization’s Workflow-to-Transactions Task Group passed a new standard transaction for automating electronic prior authorization. The NCPDP’s work groups represent true collaboration among competitors. These are volunteers who spent their weekends and evenings negotiating standards in the interest of the greater good. The standards and business solutions for automating e-prescribing workflows are one way of clearing the way for PBMs, EMRs, and vendors like NaviNet and our partner CoverMyMeds to begin the work to get online determinations for PAs, allowing you to get the answers via NaviNet and not via fax.
The Rise of the Retail Pharmacy Clinic
Against the backdrop of accountable care initiatives, we had many conversations about real-life examples of ways patients, doctors, PBMs, and health plans could save money and deliver good care...and what the role of the pharmacy/pharmacist looks like in different use cases. One scenario we heard over and over was the quick-clinic, whether in a pharmacy or supermarket network. Think about it: In this scenario, the macro issues of freeing up primary care physician (PCP) office time for routine flu shots and other quick diagnoses gives time back to the PCP for the more complex cases, while employers get back valuable hours employees are not having to go to multiple healthcare providers for themselves and family members for routine items that can be procured during nonworking hours. Many recognize this notional drive to efficiency as a famous Clayton Christensen theme.
Taking this thought one step further, we speculated on how to better leverage and tie the information between pharmacies and physicians—and talked about the tools a pharmacist could use to signal back to a physician as part of the healthcare network. No prescription drug data would be disintermediated or in isolation, which is a major concern of the Office of the National Coordinator for Health Information Technology (ONC).
Data is King
You may have heard the old saw, “It’s not what you make, it’s what you spend.” That was definitely another theme at NCPDP this year. Cost-based reimbursement—upstream…downstream…mid-stream—and the impact of drug pricing benchmarks were the name of the game. Throw in couponing and complex multi-jurisdictional tax accounting and discounting—not to mention the specter of counterfeits and grey market activity entering the U.S. pharmaceutical market—and reaching a precise data point is challenging, to say the least.
We also visited with a plethora of provider data management vendors in the exhibit halls. Great provider data is gold. Think about it. As evidence-based care models proliferate, the efficacy of the provider data will determine the winning teams.
Dr. Carolyn Clancy: “Tell Me What You Heard”
Finally, we want to recognize NCPDP keynote speaker Carolyn M. Clancy, M.D., director of the Agency for Healthcare Research and Quality (AHRQ). She challenged everyone in the room to put patients first and stressed the imperatives of patient safety, quality, and “getting to HOW.” One anecdote Dr. Clancy told has stayed with us. She was treating patients at a clinic and overheard a pharmacist giving a really lengthy explanation about a prescription to a young woman patient. Dr. Clancy’s “aha” moment came when the pharmacist said to the patient, “Tell me what you heard.” In closing, Dr. Clancy was clear that the “real thunder” is making clinical data increasingly electronic. We couldn’t agree more.
Were you at AMCP or NCPDP? What do you think about the specialty drug conundrum? Want to tune into the recordings of our “Live From AMCP or NCPDP Radio Shows”? Continue the discussion by commenting on our blog, and connecting with us on Twitter, Facebook, and LinkedIn.