Challenges of Integrating Medical and Pharmacy Benefits in Specialty Pharmacy

San Antonio—Employers and managed care organizations alike are seeking ways to support the appropriate use of specialty pharmacy drugs; manage their utilization and cost; optimize site of service; and increase provider, client, and member satisfaction.This was presented at an AMCP meeting session, titled Integrating the Medical and Pharmacy Benefits in Specialty Pharmacy. Beckie Fenrick, PharmD, MBA, Cambridge Advisory Group, told the audience the top 2 goals for management of specialty pharmacy are the reduction of inappropriate utilization and reduction of drug acquisition cost, followed by improving adherence and persistency. See Figure.

Matthew Mitchell, PharmD, MBA, SelectHealth, also cited price increases, the number of drugs in the pipeline, and the expansion of drug indications as payer concerns. According to a recent survey conducted by the Midwest Business Group, 78% of employers nationwide have a low to moderate understanding of specialty pharmacy. Additionally, 70% don’t know how much of their specialty pharmacy spending was paid through their medical plan, and 40% were unaware how much was paid through their pharmacy plan. In separate findings, 66% of employers and 63% of health plans admitted they do not use a pharmacy benefit organization or other vendor to track their specialty drug spending under medical.

Most employers are still using traditional plan designs; however, traditional management and reporting lacks pharmacy and therapeutics committee review on the medical side, with only high-level medications or medication classes being reviewed, according to Dr. Mitchell. In addition, a large combination of drugs, both self-administered and infused, reside on the medical benefit rather than the pharmacy benefit. Newer approaches utilize specialty/injectable steering committees, composed of medical directors, pharmacists, operations management, and other stakeholders. 

“We evaluate therapeutic classes as a whole instead of in silos. This process helps us determine the most cost-effective products despite the type of benefit. As cost-effective products are determined, we can implement utilization management techniques across benefits. We can also implement strategic processes around the most efficient procurement and delivery of these products,” Dr. Mitchell said. 

Site of service options for specialty medications on the pharmacy benefit include retail, mail order, and specialty pharmacy. The physician’s office, free-standing infusion center, home infusion, and outpatient or inpatient facility are options for the medical benefit. Site of care programs, said SuAnn Stone, RPh, RegenceRx, are designed to achieve more competitive cost structure and reduce the overall spending in specialty medical/infused medications. These programs also evaluate the need for limited specialty medication and infusion distribution across all current provider types contracted, as well as standardize costs and contracts across plans. They can identify related quality alternative sites of care that can demonstrate improved outcomes, develop new benefits and policies that create strong incentives to direct members to preferred provider locations, and remove waste from the system.

Other potential savings opportunities include expanding the immunizations/therapeutic injections that can be given by pharmacists, and medication cost integration, which would steer prescribers and members to medications that have the best value, regardless of where they are covered, and drive a holistic treatment approach in patient care to obtain the best potential for outcomes at the best price.

Dr. Mitchell told the audience that, in the future, we can expect more incentive programs and removal and/or modification of the traditional “buy and bill” as a revenue generator.