Specialty Drugs Remain a Top Concern Among Employers

Employers and health plan sponsors are concerned about the inappropriate use of specialty medications that are high cost and that patients may not need. Controlling these costs but ensuring access to those who need these medications is a priority for sponsors, according to a survey by Pharmaceutical Strategies Group (PSG). PSG’s survey included 171 benefits leaders representing plan sponsors of an estimated 41.4 million covered lives.

Respondents ranked their goals related to managing specialty medications in the coming year as part of PSF’s Trends in Specialty Benefit Design Report. Reducing inappropriate utilization ranked highest for 37% of all respondents, as well as 35% of employers, and 50% of health plans.

Tracy Spencer

“They want to make sure there has been an appropriate clinical review and this medication is appropriate,” Tracy Spencer, senior vice president and practice leader of employer groups, labor, and health systems at PSG, said in an interview. “I've never had an employer say to me that they weren’t willing to pay for a therapy that was medically appropriate. But they are concerned about a lack of information surrounding reporting on what is happening with these drugs. Are these drugs working? Are our industry partners able to report on the outcomes of these drugs? They want to know that the money is well spent.”

Employers and sponsors want to know that sound plan decisions have been made, but this will require an increased level of disclosure across the pharmacy industry, Spencer said. “Once these drugs are being dispensed or administered to their population, they’re looking for outcome information and proof that drug that they are investing all this money in is actually working and working the way that it is supposed to.”

PBMs do provide employers and sponsors with information about savings generated from utilization management efforts, such as prior authorization and step therapy. In fact, more than 80% of plan sponsors have access to reporting on their total healthcare costs. But what employers really want is specialty patient management and not just cost savings. PSG’s survey found, however, that clinical outcomes of adherence, persistency and clinical efficacy were reported less often (71% and 31%, respectively).

“Employers now are demanding that the patient management aspects be inserted back across all of their specialty patients, not just rare disease states. We’ve seen the industry evolve away from that.”

Specialty pharmacies, Spencer said, shouldn’t only focus on costs but also on patient management, assessing outcome of therapies and whether the drugs are doing what they should be doing. “We need to focus back on the clinical pieces of specialty,” she said.

This interest in specialty patient management started before the COVID-19 pandemic but had been put on hold by many companies as they focused on different priorities, Spencer said.

Other findings from the PSG’s specialty benefit design report:

• More than 90% of plans use prior authorization, step therapy, and quantity limits as management strategies;
• More than 50% use at least one strategy to increase the use of biosimilars;
• 70% of plans can track specialty drug spend separately under the medical benefit, an increase from the 50% reported in 2019;
• 43% of plans have more than one specialty cost-sharing tier;
• 20% of plans can track patient treatment delays due to new to market blocks;
• 8% of plans are currently using alternative funding models, while 31% are exploring their use.