Strategy and Balance: Managing Costs for Pulmonary Arterial Hypertension

Plan sponsors have many options to control spend while ensuring member access

BRIEFING
April 19, 2022
Vice President, Product Development, CVS Health

Pulmonary arterial hypertension (PAH) is a rare, progressive disease for which there is no known cure.

Estimates of monthly health care costs of patients with PAH are wide ranging, from $2,200 to $9,300. Studies have found that patients with PAH have significant pharmacy costs driven by high drug utilization.Sikirica M, Iorga SR, Bancroft T, Potash J. The economic burden of pulmonary arterial hypertension (PAH) in the US on payers and patients. BMC Health Serv Res. 2014;14:676. Published 2014 Dec 24. doi:10.1186/s12913-014-0676-0 To complicate matters, PAH is often treated with infused drugs that can be billed under the medical benefit with limited visibility to spend.

Combination therapy for PAH is quite common: 46 percent of PAH patients are on dual and 9 percent are on triple therapy regimens, potentially increasing costs for payors.Highland KB, Hughes KE, Williams KJ, Kyei-Baffour B, Ferguson S. Ensuring appropriate access to pulmonary arterial hypertension therapy. Am J Manag Care. 2019;25:S119-S127. However, TRITON, a pivotal trial on double and triple therapy, demonstrated marked improvements in pulmonary vascular resistance (PVR) as compared with baseline, a superior outcome to historical progressive therapy escalation.TRITON: The Efficacy and Safety of Initial Triple Version Initial Dual Oral Combination Therapy in Patients with Newly Diagnosed Pulmonary Arterial Hypertensionhttps://www.jacc.org/doi/10.1016/j.jacc.2021.07.057 These patients are living longer and avoiding the need for lung transplants.

What cost management strategies are available for PAH therapies?

Plan sponsors can help reduce costs and enhance care with our comprehensive management approach to PAH, which couples appropriate medication regimens with in-depth counseling and adherence support to generate better outcomes.*

Our approach is rooted in these critical strategies helping clients effectively manage their pharmacy costs while ensuring minimal member impact:

First, our formularies ensure we start therapy with certainty by providing clinically appropriate and lowest net cost products for our clients. Our Advanced Control Specialty Formulary (ACSF) incorporates multiple strategies for a proactive approach to managing specialty costs. This includes Specialty Guideline Management to help ensure clinical appropriateness, drug safety and effectiveness.

ACSF delivers value through step therapies, tiering strategy, robust clinical reviews and quantity limits across the various classes of the formulary. The formulary design also promotes generics first to increase utilization of lower-cost, clinically appropriate options where available.

Second, our digital connectivity and advanced analytics help effectively eliminate waste throughout therapy. Supply Management Optimization** helps patients manage their drug supply, so they have the right amount of medication on hand using a rolling 365 days of supply. We control the utilization of medications by detecting and taking action to optimize supply on-hand, ensure drug efficacy – and help prevent excess drug accumulation.

Third, we use connectivity with both members and their providers to proactively intervene when needed to reduce adverse and costly events from ineffective treatment. Our Intelligent Medication Monitoring† solution uses data analytics and our digital infrastructure to identify when patients may no longer be benefitting from their treatment and intervene appropriately. This proactive surveillance enables us to identify gaps in care and monitor efficacy, symptoms, pain and exacerbations.

Given our high level of digital engagement, we can adapt our message to members and reach them through a channel of their preference. When appropriate, we can work with providers to deliver targeted interventions, including stopping treatment or changing to a different therapy. These digital strategies leverage patients’ increasing digital adoption to better engage PAH patients and their providers to help manage utilization throughout therapy.

Actionable insights on PAH plan performance and patient management include

  • Trend insights – therapy-level insights to understand key spend drivers
  • Population and therapy details – flexible tools to review and drill down to key drivers of spend and trend
  • Behavior activation – analysis of patient engagement and effectiveness of digital communication
  • Therapy management – opportunities and continuous management to support high-quality, cost-effective care
  • Outcomes and savings – results to show clinical actions, behavior change outcomes and trend impact

New PAH therapies are pending FDA approval and are expected to launch this year. CVS Health helps clients navigate the novel PAH pipeline landscape:

Monitor

Develop and circulate

Assess and formulate

Analysis and modeling - baseline projections

External panel review and thought leadership

Marketplace collateral: proactive client breifings, white papers, published literature

Drug launch awareness: specialty drug approval and launch alerts

Client-specific reporting

Refined budget-impact modeling

Strategic plan design options to help mitigate spend

Post-launch analysis and trend forecasting

Trade and formulary strategies

We have a broad set of tools to help clients manage spend in PAH and other conditions that require specialty medications. We take a consultative approach to addressing new drugs in the pipeline and generate prospective reports on utilization. Through our robust reporting that clearly demonstrates results, payors can see their savings drivers and understand the real value of our integrated approach.

Questions about how to balance spend and access for members with PAH? Ask Us
BRIEFING
April 19, 2022
Vice President, Product Development, CVS Health

*These are pharmacy benefit management options that clients may include in their plan design. Not applied without client election.

**SMO is a specialty pharmacy service performed by CVS Specialty pharmacy for members of select contracted PBM and CVS Specialty standalone payor clients who fill specialty prescriptions through CVS Specialty and is included as a core service in the payor agreement.

†CVS Specialty pharmacy patients only