PHILADELPHIA Acro Pharmaceutical Services, in conjunction with Armada Health Care, hosted the third Annual Regional Payer/Managed Care Symposiumm here on Dec. 11 at the Hyatt Regency-Penn's Landing.
Anchored by an in-depth panel discussion with representatives from top national and regional payer organizations — including, Aetna Specialty Pharmacy, Amerigroup, Health Partners of Philadelphia, Independence Blue Cross/Future Scripts, Johns Hopkins Health Plan, Passport Health Plan and Perform Rx — the event also featured a dual keynote presentation from Mark Thierer, president and CEO at SXC Health Solutions, and Mark Adkison, the company’s SVP mail and specialty. Thierer and Adkison focused their remarks on healthcare reform and how integrated healthcare data can help drive compliance rates and optimize the drug spend for payer groups.
Key points from the panel discussion, which focused on management strategies for high cost specialty drugs and how health reform will likely affect managed care pharmacy utilization, included —
- Specialty pharmacies, whether in-house or outsourced to vendors, are important partners for health plans in terms of implementing formulary and utilization management
- Health plan priorities for managing specific specialty categories are based on two factors: category spending; and opportunity for category management (e.g., categories with multiple competing products present a greater opportunity)
- Payers’ specialty management perspectives can vary by lines of business (commercial vs. Medicaid vs. Medicare)o For commercial plans, employers (especially those who are self-funded) drive benefit design decisions and the general cost control philosophy for specialty drugso For Medicaid plans, there might be constraints within the context of state regulations (states may legislate preventing implementation of formulary or utilization management in select therapeutic areas)o For Medicare plans, population dynamics (e.g., prevalent conditions in elderly population) is an important factor
- Management of specialty drugs relies on effective coordination between pharmacy and medical benefitso Ability to coordinate between these benefits may vary among plans; for some plans division between pharmacy and medical benefits might be rather artificial, while for others it is driven by benefit design
- Key specialty management strategies focus on network/distribution channels, formulary management, benefit design, as well as utilization, disease, and case managemento Regardless of what specialty management strategies are used, it is critical to maintain alignment between stakeholder incentives; any imbalance can shift utilization to more costly sites of care and/or create provider network disruptionso Payers expect greater use of formulary and utilization management techniques in the area of specialty drugs (including oncology)
- Payer experience shows that most savvy account managers serve as effective liaisons between their accounts and their corporate teams in adequately representing interests of their customers.