Specialty drugs are drawing much attention from patients, providers, payers, and policy makers due to their high prices and aggregate impact on healthcare costs.1 Only 1% to 2% of patients in the United States use specialty drugs, but they account for up to half of a payer’s total drug spend under the medical benefit.2 In addition, specialty drugs represent a growing proportion of overall healthcare spending.
To address the rising drug costs, especially in oncology, health plan sponsors and managed care organizations are increasingly using clinical pathways to maximize the medical benefit management (MBM) of specialty therapies.3 Implementing clinical pathways helps reduce the substantial variation in patient care across oncology treatment plans. Using pathways also enables standardization of the care process and promotes adherence to evidence-based and established protocols impacting safety, efficacy, and total cost of care.
From 2011 to 2016, 222 US oncology programs were identified that utilized internally developed clinical pathways or pathways from independent vendors (Figure 1).3 One of the pathway vendors gaining prominence is Via Oncology, which was purchased by Elsevier in 2018. The goal of these combined companies is to support healthcare professionals in improving oncology treatment options and patient outcomes by leveraging Via’s pathways while reducing system variation and cost in the United States and globally.4 Recently, Intermountain Healthcare selected Via Oncology to provide clinical pathway solutions for Intermountain’s Oncology Clinical Program and support the management of oncology therapies administered under the MBM.
Another strategy to address rising drug costs is the integration of medical and pharmacy benefits management through partnerships, mergers, and acquisitions. Examples include the Express Scripts (ESI) acquisition of eviCore, the pending mergers of CVS-Aetna and Cigna-ESI, and the creation of CVS-Anthem’s internal PBM, IngenioRx. These partnerships will address one of the major barriers to integrated care—medical benefits and pharmacy benefits being managed by separate entities not considering the total cost of care—and focus on integrating drug utilization data, benefits, and management. This will allow for the application of common principles across all benefit designs whether the drug is covered under the medical benefit or the pharmacy benefit. Control over both benefits will enable these entities to more effectively manage and leverage drug costs for patients and payers.5
In this new value-based era with the rapid evolution of specialty and other expensive drug therapies, mergers and contractual integration of pharmacy/medical data and operations will continue apace. More organizations will institute clinical pathways to support the management of specialty therapies. Manufacturers should seek to understand where their products fit on these pathways and how pathways differ by vendor. In addition, the integration of utilization data as well as pharmacy and medical benefit management may offer payer–manufacturer partnership opportunities using the robust real-world data that can now be collected by a single entity.
- Hirsch BR, Balu S, Schulman KA. The impact of specialty pharmaceuticals as drivers of health care costs. Health Aff (Millwood). 2014;33(10):1714-1720. https://www.ncbi.nlm.nih.gov/pubmed/25288414. Accessed April 3, 2018.
- Magellan Rx Management Medical Pharmacy Trend Report. 7th ed. https://www1.magellanrx.com/media/604882/2016mrxtrendreport_final.pdf. Published 2016. Accessed April 3, 2018.
- Schroeder A. Clinical pathways: a current snapshot, and the journey ahead. J Clin Pathways. 2017;3(2):33-40. https://www.journalofclinicalpathways.com/article/clinical-pathways-current-snapshot-and-journey-ahead. Accessed April 3, 2018.
- Pennic J. Elsevier acquires clinical decision support solution Via Oncology. HIT Consultant. http://hitconsultant.net/2018/01/18/elsevier-acquires-via-oncology/. Published January 18, 2018. Accessed March 2, 2018.
- Japsen B. Express Scripts to buy eviCore for $3.6B as value-based care takes hold. Forbes. https://www.forbes.com/sites/brucejapsen/2017/10/10/express-scripts-to-buy-evicore-for-3-6b-as-value-based-care-takes-hold/#24fb6c7d7c4b. Published October 10, 2017. Accessed April 3, 2018.