Today, the predominant spend in the pharmacy category is going toward specialty medications. Crafting an approach to address any concerns your clients might have today around how they might better utilize their funds to provide a clinically and economically sound benefit are a bit different [than 10 or 20 years ago]. At RxBenefits, we’ve created a number of programs to eliminate utilization of low clinical value drugs, to encourage use of lower-cost brands and generics whenever possible, preventing off-label use, preventing inappropriate use, and in particular for specialty medications, making sure that it’s the right drug for the right patient at the right time in the right dose.
To give you an example, there are a lot of drugs that are very popular in the specialty category. Anti-inflammatories would be one. In some instances, there can be dose creep over time, where we see people using more dose or more frequency for those medications. Sometimes that’s appropriate and sometimes that’s not appropriate, but inappropriate use of a specialty medication can cost a plan $60,000 or more. We’ve found some instances where dose optimization has led to savings as great as $720,000 a year for a single patient. While that may not be common for all employers, it’s important to have programs in place that are going to look for those types of opportunities.
Knowing the Ideal Time to Implement Clinical Programs
Regardless of whether or not we are in a time of expansion or a time of contraction, it’s never a good idea to pay $60,000 when you shouldn’t or pay $500,000 when you could pay $300,000. As you are meeting with your clients and you are dealing with their expectations going forward to help better manage their plan, keep in mind that there are things that can be done that are low impact to members but can have a high yield for the employer in terms of savings. Our job here is to make sure that you understand the opportunities, what the relative values of those opportunities are, and what the impact to membership is so that you can be prepared to make changes throughout the year or at the plan renewal.
One of our early adopters was a school system. They needed to save some money and were looking for ideas and recommendations, so we put our programs in place for them. They immediately saw a reduction in their expense of about $200,000 per month. We closely monitored to see how the program was going and to see what impact it had on their members, and they had no negative feedback for us from their membership. They were extremely pleased with the savings being generated and the fact that it wasn’t having a stressful impact on their membership.
The salient point here is that there are things that can be done. They are reasonable, appropriate, and affect very few people. They provide a protective measure to keep from paying for things your clients shouldn’t be paying for in the first place, while delivering a long-term benefit that prepares them for what’s coming in the future as new products come to market. It’s easier to address utilization at the point of care or at the point of dispensing instead of having to go back at some point in time and address this after the patient has already been acclimated to taking the medication for some period of time.
Nonetheless, whether your circumstance is that you already have some inefficiencies that need to be reconciled or you’re preparing for the future, these programs can provide an extraordinary benefit. We can help you understand for your book of business what the relative value of that is in terms of cost and impact on members.
To learn more about the market practices impacting your self-funded clients – and what you can do about it – check out our free e-book, Building an Optimized Clinical Playbook.