Specialty Pharmacy + Medication Assistance Programs Presenters: Scott Sterrett, PharmD Manager, Specialty Pharmacy Beaumont Health
FACULTY DISCLOSURE The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CE activity: - Scott Sterrett - Nothing to disclose
Who s in the Audience? A. B. C. D. IDN Pharmacy Executive Other IDN Executive Pharmaceutical Industry Other
Tell Me About Your Site A. No specialty pharmacy (SP) B. In process of developing/implementing SP C. Well-established SP D. Don t know/not sure
Session Objectives 1. Detail the factors causing uncertainty and financial hardship for pharmacy patients. 2. Identify three assistance programs that can help mitigate these burdens. 3. Discuss the impact these programs have on patients and providers.
What Are Specialty Drugs? High cost Treatment requires special monitoring Treats orphan, uncommon, or rare disease Special handling, storage, or distribution Limited distribution from manufacturer Treats disease already classified as specialty Requires patient administration training EMD Serono Specialty Digest: 10 th Edition (2014)
Specialty Spans Multiple Care Settings Route of Administration Oral and self-injectable Infusion centers Home infusion Insurance Coverage Prescription benefit Medical benefit
The Rising Cost of Specialty Medications Peterson Kaiser Health System Tracker. Recent and forecasted trends in prescription drug spending (2017)
Increased Cost-Sharing Specialty drug tiering High-deductible health plans Copay accumulators
Specialty Drug Tiering 76% have specialty drugs in separate cost-sharing tiers 59% have two or more specialty tiers Median specialty copayment is $ 100 Average specialty copayment is $ 107 EMD Serono Specialty Digest: 10 th Edition (2017)
The Rise of High-Deductible Health Plans National Center For Health Statistics. National Health Interview Survey (2018)
HDHP Cost Sharing EMD Serono Specialty Digest: 10 th Edition (2017)
Copay Accumulators Manufacturer copay cards do not count toward prescription deductible or out-of-pocket costs Many plans began adopting in 2018 Out of Pocket Protection Program Coupon Adjustment: Benefit Plan Protection Program Fein AJ. Drug Channels. http://www.drugchannels.net/2018/ 01/copay-accumulators-costly-consequences.html
The Result
Ease of Affording Prescription Medications 1% Very Easy 9% Somewhat Easy Somewhat Difficult Very Difficult 17% 45% Don't Have to Pay 28% Peterson Kaiser Health System Tracker. Recent and forecasted trends in prescription drug spending (2017)
Globally 1 Financial Barriers Lower Adherence 20-30% of prescription medications never filled 50% of medications for chronic conditions taken incorrectly Medicare patients prescribed imatinib 2 32% failed to fill within 6 months Lack of low-income subsidy correlated with failure to start therapy 1 Ann Intern Med 2012;157(11):785-95. 2 J Clin Oncol 2016;34(36):4323-28.
Financial Barriers Lower Adherence All insured patients who applied for copay asssistance 3 42% reported significant or catastrophic financial burden 46% reduced spending on food and clothing 46% used savings to defray out-of-pocket expenses 20% took less than prescribed amount 19% partially filled prescriptions 24% avoided filling prescriptions entirely 3 Oncologist 2013;18(4):381-90.
Types of Financial Assistance 1. Manufacturer-sponsored copay cards 2. Charitable foundations 3. Manufacturer-sponsored free drug programs 4. 5. Drug replacement programs Health system financial assistance
1. Copay Cards Manufacturer-sponsored Available for most medications Copay amount and maximum benefit vary Generally no financial requirements Cannot be used for federallyinsured patients
2. Charitable Foundations Available for many specialty disease states Eligibility and funding vary by program Patients with federally-funded insurance are eligible Examples CancerCare Co-Payment Assistance Foundation Chronic Disease Fund HealthWell Foundation Patient Access Network Foundation
3. Free Drug Programs Manufacturer-sponsored Need-based, generally percent of FPL Require insurance denial or proof of uninsured status Can be used for all patients
4. Drug Replacement Manufacturer-sponsored Drug-specific program Pre-administration vs. post-administration May use for off-label indications Require insurance denial or proof of uninsured status Can be used for all patients
5. Health System Financial Assistance Use as last resort Charity care/340b benefit Eligibility varies by system
Patient Benefits Increase access to medications Supports adherence Improved outcomes/disease management Reduced financial burden
Provider Benefits Better manage population health Decrease emergency visits/readmissions Decrease bad debt/charity care (maybe) Increase specialty pharmacy revenue
Medication Assistance Survey Informal survey of Vizient Specialty Pharmacy listserv Assess types of assistance provided to patients receiving specialty medications Seven responses from Academic Centers Vizient AMC Network Survey (2018)
What types of financial assistance do you provide for specialty patients? (n=7) 7 7 7 6 MFG COPAY MFG FREE DRUG THIRD PARTY SYSTEM FUNDS Vizient AMC Network Survey (2018)
What is the approximate percentage of funds provided by each source (n=6) 58 28 15 MANUFACTURER CHARITY HEALTH SYSTEM Vizient AMC Network Survey (2018)
For what medications do you provide health system-sponsored funds? (n=6) 5 5 4 ORAL SELF-INJECTABLE INFUSED Vizient AMC Network Survey (2018)
Have you seen a decrease in the amount of system-sponsored funds since implementing your specialty pharmacy? (n=6) 3 2 1 YES NO UNSURE Vizient AMC Network Survey (2018)
Case Study BEAUMONT HEALTH SPECIALTY FINANCIAL ASSISTANCE
Beaumont Health Overview 8 hospitals; 3,429 beds 5,000 physicians 187 outpatient sites 175,688 discharges (2017) $4.4 billion net revenue (2017) 5 infusion centers Specialty pharmacy implemented 2014
Locations of Care Specialty Pharmacy Oral and self-injectable Serve employees, clinics, and BH providers Pharmacy benefit claims Infusion Centers Infused therapies Variation in funding assistance across sites No integration with SP
Specialty Pharmacy Assistance Staff 2 dedicated Prior Authorization Technicians Comprehensive approach to medication access Types of Assistance Offered Manufacturer-sponsored copay cards and free drug Charitable organizations
Assistance Secured Patients Served Specialty Pharmacy Financial Assistance Secured $4,500,000 $4,000,000 $4,220,340 615 700 600 $3,500,000 $3,000,000 $2,654,288 $3,798,547 500 $2,500,000 $2,000,000 $1,142,780 395 400 300 $1,500,000 $1,000,000 $500,000 110 243 200 100 $0 2014 2015 2016 2017 0 Over $11.8 million secured to-date
Infusion Center Assistance Relatively new process for infusion centers Primarily drug replacement and copay cards Troy Ambulatory Infusion Center (2017) $1.26 million worth of drug replacement $456,000 decrease in bad debt due to copay programs
Financial assistance touches the lives of both patients and providers
Contact Information Scott Sterrett, PharmD Manager, Specialty Pharmacy Beaumont Health scott.sterrett@beaumont.org