How Data and Analytics can be Leveraged to Manage Specialty Drugs

Vivio Health doesn’t use a formulary to manage specialty drug costs. Company executives don’t even consider the company to be a PBM.

Pramod John

Vivio Health is independent data-driven intermediary, according to Pramod John, CEO. “Our argument is that PBMs almost always focus on cost as a primary dimension to contracting, and all the major PBMs own infrastructure themselves,” he said in an interview “We are not paid by pharma companies or anyone else and our decisions are devoid of those influences.”

Vivio Health works with large, self-insured companies that pay a fixed, per-member, per-month fee for its services in managing specialty drugs. The company uses data and analytics to help determine the best therapy for each patient. The company’s system, Vivio qClinicals was developed in-house to include clinical trial data of drugs to treat specialty conditions, such as Crohn’s disease, cancer, HIV, multiple sclerosis, hepatitis C and others. Individual patient data from the electronic medical record are collected from the treating physician to match the patient with therapies that would benefit that specific patient.

“We focus on the underlying data to determine whether we think the drug is useful and whether the drug actually does provide benefit to quality of life or life expectancy.”

He gives the example of Humira and Enbrel for rheumatoid arthritis. “The therapies benefited about 40% of the population that were in the trial. Because nobody's done an end-to-end, crossover trial, we actually don't know whether that 40 out of 100 in Enbrel is the same 40 out of 100 for Humira. They could be overlapping populations or not. We don’t know.”

They may not be interchangeable, he said, so excluding one or the other from a formulary is not based on the data. The company database of clinical trial results would help to determine which patients would benefit from either Humira or Enbrel.

Because Vivio Health’s services are fee based and not based on rebates, the company is not invested in the use of specific therapies for specific conditions. “It makes no difference to us whether someone’s on an expensive drug or cheap drug,” John said.

But he said that an open formulary doesn't mean that anyone can use any drug. “It means everyone has access. It means if data support the use of a drug for someone, that drug would be covered. Not everyone needs the same drug.”

At the same time, the company, John said, issues very few denials for therapies. “Our process is not designed around denials, but around ‘how do we agree to the right thing for the patient.’”

Vivio Health works with physicians to access each patient’s electronic medical record. And then based on the patient’s own condition, medical history and medications, the treating physician would be presented with possible therapeutic options for each patient, as well as a determination of the cost-effectiveness of each therapy.

Bhargav Raman, M.D.

The question physicians face is what therapies are going to work for their patients, said Bhargav Raman, M.D., director, clinical product, at Vivio Health. “Our model takes the patient data, both historical and current state and matches that with the drug trial data to find out which drugs are appropriate for this patient. It’s almost like an individualized formulary.”

In areas such as genetic diseases and oncology, the patient’s genetic data and other information such as the receptor cells shown in the tumor, are also put into the company’s model, Raman said.

“An appropriate escalation management strategy for that particular patient would be based on that data matched with the data from trials, inclusion criteria, and population analyses, etc.”

But John said this isn’t like traditional step therapy. “The reason a formulary exists is because it drives rebates in a certain way,” he said “It generally is an economic, for-profit optimization for the people in the middle. We’ve taken a commonsense approach to say, ‘if you don't have any data and if it were our money, we would pick a lower cost one. And if that doesn’t work, let’s look at the obvious next steps.’”

John said the company is transparent about the costs of specialty drugs. But the decision about which drugs to prescribe is made by the patient and the treating physician. Vivio Health works to partner with physicians for these often-complex cases.

Physicians, he said, are generally open to the information provided by Vivio Health, especially if they practice in universities or in large hospital systems where discussions of cost-effectiveness of therapies are more common. “Many physicians are happy we don’t have a formulary,” he said.

The company’s clients, John said, are also happy because Vivio Health’s spend on specialty drugs is about half of what the national benchmarks are across large PBMs. In 2020, clients saved 37% on specialty drug spend when they switched to Vivio Health’s services.