Large Cost Claimants: What They Are & How to Address Them

When new drugs come to market for rare diseases – those that affect less than 200,000 Americans, often these obtain orphan drug status. They’ll go through the Food & Drug Administration (FDA) approval process more quickly and will contribute to the increase in costs that we see with specialty medications. A lot of times we think that when someone has a rare disease, they’re being treated by a specialist and it is what it is – whatever therapy they are receiving is appropriate and that must be what they need. There’s an acceptance that there aren’t any cost-saving opportunities nor opportunities to optimize the therapy. When we look closely at these cases, we see that simply isn’t true.

What we’ve been able to do is review these cases of drugs with the potential to hit $250,000 or more, using a peer-to-peer outreach. It’s been surprising with some of the results we’ve found through our analyses of rare diseases. We’ve found that there is an opportunity to optimize the therapy with some of these individuals.

One example of this occurred with a client of ours who had a member filling a prescription for Somatuline, which is a medication used to treat acromegaly. In this particular case, the member was being treated monthly and was receiving four syringes per month. The annual cost was approaching over $300,000 in spend for this one member on this one prescription drug. We were able to provide a peer-to-peer outreach for this situation. Upon that outreach, we worked with a prescriber in that same specialty who reached out to the specific prescriber of the member’s claim. That specialist identified an error in the dosing: the member should have been receiving one syringe per month as opposed to the four syringes per month.

This outreach resulted in a change to get the member the more appropriate therapy of one syringe per month. For the plan, this change decreased the cost quite significantly. Looking at the annualized cost of the medication, it was an annualized savings of over $200,000 per year. Again, this is surprising if you think that these drugs are being managed already and that there are no optimization opportunities. We realized there was an opportunity for this particular case because of that peer-to-peer review.

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