Care site has big impact on costs

Abstract

As specialty pharmacy costs become increasingly relevant in managing the overall cost of health care, third-party payers have increased their attention to sites of care. This is important because many, if not most, self-administered specialty products are now billable under a patient's pharmacy benefit, yet one-half of specialty pharmacy expenditure still happens on the medical side.1.http://info.cvscaremark.com/sites/default/files/Insights%202013.pdfGoogle Scholar Through closer oversight of these products, managed care organizations can carefully manage the access and distribution of such products through pharmacy networks and specialty pharmacy providers and also manage costs through formularies and rebates. As specialty pharmacy costs become increasingly relevant in managing the overall cost of health care, third-party payers have increased their attention to sites of care. This is important because many, if not most, self-administered specialty products are now billable under a patient's pharmacy benefit, yet one-half of specialty pharmacy expenditure still happens on the medical side.1.http://info.cvscaremark.com/sites/default/files/Insights%202013.pdfGoogle Scholar Through closer oversight of these products, managed care organizations can carefully manage the access and distribution of such products through pharmacy networks and specialty pharmacy providers and also manage costs through formularies and rebates. View Large Image Figure ViewerDownload (PPT)Pharmacy providers can help manage site of care and medication access. Health plans can work with specialty pharmacy providers to arrange specialty medications via traditional buy-and-bill techniques, or via "brown bagging" or "white bagging" policies (Figure 1). Such policies are not without their challenges, however, as these procedures can potentially increase administrative burdens and other costs on the clinics providing the administrative services. Pharmacy providers can potentially address these challenges by establishing relationships with clinics or home infusion services.Figure 1Common methods of delivering medication to sites of careView Large Image Figure ViewerDownload (PPT)Specialty medications that require health professional supervision or administration can be administrated in a variety of settings, including hospital outpatient clinics, physician offices, infusion centers, or homes. As of 2013, the top four health professional-administered medications included infliximab (Remicade—Janssen), pegfilgrastim (Neulasta—Amgen), rituximab (Rituxan—Genentech, Biogen IDEC), and bevacizumab (Avastin—Genentech), with approximately 19% to 44% of the total claims for these medications administered in a hospital outpatient setting, versus a physician's office or at home.2.www.magellanrxinsights.com/Google Scholar As one might expect, the cost of both the drug and administration can differ significantly based on site of administration. The cost of infliximab, for example, can vary by 30% to 115% depending on site of administration.1.http://info.cvscaremark.com/sites/default/files/Insights%202013.pdfGoogle Scholar By encouraging a member to receive this product in a physician's office or at home, managed care organizations can potentially save significantly on product costs per year.The expected increase in specialty pharmacy products over the next several years will continue to raise discussions of coverage policies and management strategies within managed care organizations. By thoroughly understanding the needs and requirements of managing such products, payer groups can help manage the growing costs of specialty products by working with pharmacy providers in directing patients to lower-cost sites of care, while continuing to provide high-quality services and patient care. Pharmacy providers can help manage site of care and medication access. Health plans can work with specialty pharmacy providers to arrange specialty medications via traditional buy-and-bill techniques, or via "brown bagging" or "white bagging" policies (Figure 1). Such policies are not without their challenges, however, as these procedures can potentially increase administrative burdens and other costs on the clinics providing the administrative services. Pharmacy providers can potentially address these challenges by establishing relationships with clinics or home infusion services. Specialty medications that require health professional supervision or administration can be administrated in a variety of settings, including hospital outpatient clinics, physician offices, infusion centers, or homes. As of 2013, the top four health professional-administered medications included infliximab (Remicade—Janssen), pegfilgrastim (Neulasta—Amgen), rituximab (Rituxan—Genentech, Biogen IDEC), and bevacizumab (Avastin—Genentech), with approximately 19% to 44% of the total claims for these medications administered in a hospital outpatient setting, versus a physician's office or at home.2.www.magellanrxinsights.com/Google Scholar As one might expect, the cost of both the drug and administration can differ significantly based on site of administration. The cost of infliximab, for example, can vary by 30% to 115% depending on site of administration.1.http://info.cvscaremark.com/sites/default/files/Insights%202013.pdfGoogle Scholar By encouraging a member to receive this product in a physician's office or at home, managed care organizations can potentially save significantly on product costs per year. The expected increase in specialty pharmacy products over the next several years will continue to raise discussions of coverage policies and management strategies within managed care organizations. By thoroughly understanding the needs and requirements of managing such products, payer groups can help manage the growing costs of specialty products by working with pharmacy providers in directing patients to lower-cost sites of care, while continuing to provide high-quality services and patient care.