Addressing Rising Costs and Disconnected Systems
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The fact that specialty is a high-spend category is no surprise. And its impact on payor spend is growing. For 2020, we expect specialty therapies to account for 60 percent of pharmacy spend.
Specialty drugs comprised only 1 percent of claims, but accounted for 45 percent of costs — up from 42 percent in 2017 — in our 2018 commercial book of business.
U.S. Specialty Pharmaceutical Market Size and Growth by Channel
Source: Barclays U.S. Health Care Distribution and Technology Specialty Market Model 2017 Update: A Focus on Biosimilar Opportunities, Jan 30, 2017.
This, combined with the lack of visibility in the medical benefit, makes specialty a particularly challenging management area. Often plan sponsors must make cost and coverage decisions with imperfect and incomplete information across disjointed systems – many of them manual. This makes it even more difficult for payors to help ensure the most cost-effective medication therapies are prescribed, and for providers to prescribe and access the most effective drug options efficiently for their patients.
Among the top four challenges of managing the specialty category as identified by payors:
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As the challenges – and opportunities – to effectively address specialty spend have grown, strategies that claim to do so have proliferated. But not all approaches are created equal. While most can help manage one or more different aspects of specialty therapies, few address all of the key challenges or simplify specialty management for multiple stakeholders.
At CVS Health, we utilize our integrated model to manage specialty spend across benefits and help positively impact clinical and financial outcomes. It starts at the point of prescribing where we offer visibility into the entire range of possible therapies across medical and pharmacy benefits. Our template formularies include clinically appropriate, cost-effective drug options for the specific point in a patient’s condition journey. Prior authorization (PA) through our proprietary claims technology platform, Novologix, provides greater control through diagnosis review, clinical data and response to therapy as a condition of coverage. It can also match the claim to the PA requirements and apply edits to ensure the right dose, duration and price.
How to effectively manage across benefits:
Novologix is a proprietary technology platform designed to help payors address their biggest areas of concern: coordinating across medical and pharmacy benefits with efficiency and accuracy, and managing high-spend categories including oncology. Novologix is backed by the experience of more than 23 health plans covering 47 million lives. The platform is completely customizable and can be configured to be used as a self-service tool or delegated to CVS Health.
In 2018, Novologix saved clients almost $217 million in medical savings through PA. Total savings for medical claims management and site of care for all clients in 2018 was more than $26 million.
Starting Patients on Therapy More Efficiently
Given the high cost and complexity of specialty therapies, a vast majority of payors have PA requirements to ensure appropriate utilization. About nine out of 10 specialty therapies require a PA. However, those can often be cumbersome for provider offices because they require more time and effort. Interestingly, despite many plans having an automated PA system in place, not all of them have high provider adoption. Some systems can only manage PAs for either the pharmacy or the medical benefit. More than 90 percent of physicians reported delays in care as a result of having to process PAs and 78 percent reported that it led to abandonment of the treatment plan at least some of the time.
Novologix offers online, real-time access to an automated PA process across both benefits with a single front-end system. Moreover, complete regimen approvals are available for complex cancer approvals, rather than drug-by-drug authorizations, as offered through other marketplace models. Speed and convenience is key – for providers using our portal, we find that it takes only six minutes to create a request, and as little as one minute for a decision or approval. The platform automatically chooses the appropriate benefit for the request and helps guide the process electronically. All required documentation can be requested and submitted online eliminating the need for multiple phone calls and faxes.
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Integrated Approach to Selecting Oncology Treatment
Novologix also helps simplify management of one of the most important categories of specialty medications – oncology. The National Comprehensive Cancer Network (NCCN) is an alliance of 28 leading cancer centers whose clinical practice guidelines cover all aspects of oncology, and are widely regarded as the gold standard. The guidelines cover 59 treatment and supportive care areas, representing 97 percent of all therapies, and in 2018 alone there were more than 500 updates made based on evolving treatment landscape.
However, keeping up with rapidly evolving guidelines, and trying to ensure providers are prescribing the most appropriate treatments for each patient can be challenging. Payors can set the level of evidence to match their coverage policies and management goals. And when prescribers have to submit PA requests for each drug within a regimen individually that can take up valuable time and resources.
CVS Health offers a single-step, cross-benefit, full-regimen PA process linked to the recommendations contained in the NCCN Clinical Practice Guidelines. It also allows prescribers to get an automated approval for an entire treatment regimen, even one that includes elements covered under both medical and pharmacy benefits. Highlights include:
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Ability to review all NCCN-supported regimens prior to treatment selection |
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Regimen-level dosing limits to help drive appropriate and cost-effective therapy |
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Effortless navigation through the NCCN Drugs and Biologics Compendium within Novologix |
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Peer-to-peer review by oncologist for off-guideline regimen requests |
Cross-Benefit Visibility for Tighter Overall Spend Management
Just as specialty drug dispensing is split between the medical and pharmacy benefits, so is the benefit administration. Disparate claims systems can make it harder to consistently optimize utilization. Payors are also unable to determine whether their benefit configurations are aligned and operating as intended to maximize cost control, leading to inefficiencies and hindering a plan’s ability to identify ways to optimize plan design.
Novologix enables payors to use CVS Health pharmacy benefit management services to manage pharmacy spend under the medical benefit. They can use the platform’s cross-benefit analysis capability – the ability to look across pharmacy and medical claims – to identify whether the plan design is working as intended and if members are being directed to the right medication under the right benefit.
Novologix continuously monitors indication information from the FDA and maintains a database in near real-time, which lets payors see which medications members are being directed to, as well as which benefit is being utilized to obtain these medications. The platform uniquely integrates reporting across medical and pharmacy benefits, presenting a comprehensive and detailed picture of utilization, down to which drugs were denied, why, and if any alternative medications were filled under either the pharmacy or medical benefit. Based on the denied claim or authorization, and cost and episodic frequency specific to the original and alternative medication, the proprietary technology can also calculate integrated savings for the payor.
Through cross-benefit reporting, Novologix identifies instances where processes are not functioning as desired – for instance if denial of a pharmacy benefit authorization results in a provider sending a request to the medical benefit for a more costly medication. When such concerns are identified, our clinical consultants help identify opportunities with the health plan to optimize plan design and correct inefficiencies.
CVS Health provides payors with integrated tools to comprehensively manage all the key aspects of specialty therapies that have historically proved to be a challenge. Our streamlined portal enables much of the PA and approval processes to be automated, reducing delays and the need for resources. As treatment options for cancer proliferate, we also provide real-time access to NCCN guidelines to assist prescribers in selecting the most appropriate evidence-based treatments. And, through seamless connectivity between pharmacy and medical adjudication systems, we can capture detailed reporting and help inform optimal plan design.
*Top 100 providers are ranked by PA volumes and represent 50% of all PAs submitted for the plan
CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall.
For all potential PA outcomes and medical claims management outcomes are based on the data made available to us by our clients. Actual results will vary based on benefit plan design, member demographics, programs implemented by the plan and other factors. Client‐specific modeling available upon request.
Image source: Licensed from Getty Images, 2019.
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