Site of Care Management

Specialty drug management continues to be of utmost importance to plan sponsors, which are implementing a variety of levers to try to keep spending in check while making sure their beneficiaries are receiving appropriate care. Pharmaceutical Strategies Group (PSG), an EPIC company, recently released its 2023 Trends in Specialty Drug Benefits Report, which examines the use of these strategies and overall trends in managing these costly medications.

The report, released May 3, is the 10th annual report; it previously was published under the Pharmacy Benefit Management Institute (PBMI) brand. Conducted from Sept. 20, 2022, through Oct. 21, 2022, the survey included 182 benefits leaders from employers, unions/Taft-Hartley plans and health plans representing plan sponsors of approximately 86.7 million covered lives. Genentech USA, Inc., a member of the Roche Group, co-sponsored the report with PSG.

The use of remote patient monitoring skyrocketed during the COVID-19 public health emergency, with RPM claims volume jumping by 1,294% from January 2019 to November 2022, according to a report released by Definitive Healthcare.

Since 2018, CMS added five new reimbursement codes for RPM services, and introduced five codes related to remote therapeutic monitoring in 2022. By November 2022, RPM claims volumes were already 27% higher than they were during 2021.

Internal medicine physicians were more likely to use RPM, with 28.7% of their procedure claims related to RPM. Cardiological and family practice providers ranked second and third at 21.3% and 19.4%. An analysis of diagnosis categories suggested similar trends. Essential hypertension saw the highest share of RPM-related claims at 51.0%, followed by diabetes mellitus with complications (10.4%) and diabetes mellitus without complications (6.4%).

The FDA on Feb. 2 granted approval for a self-administered version of Amgen Inc. and AstraZeneca plc’s Tezspire (tezepelumab-ekko), a biologic used as a preventive maintenance therapy for severe asthma. Pharmacy experts tell AIS Health, a division of MMIT, that the drug’s high price tag and high clinical thresholds mean that adoption is unlikely to spike in the short term.

The new version of Tezspire, a human monoclonal antibody, can be self-administered by patients through a pre-filled pen. Doses last four weeks. Tezspire is “the only biologic approved for severe asthma with no phenotype (e.g., eosinophilic or allergic) or biomarker limitation within its approved label,” per an Amgen press release. It was first approved in December 2021, But previously, the drug had to be administered by a practitioner.

The opioid epidemic — which by one measure peaked in 2017, when the Centers for Disease Control and Prevention (CDC) recorded 17,029 U.S. deaths involving prescription opioids — is far from over. In fact, CDC data show that deaths tied to prescription opioids, after declining in 2018 and 2019, came roaring back with the onset of the COVID-19 pandemic, and totaled 16,416 in 2020.

As the country continues to grapple with this stubborn issue, health insurers have learned they have a role to play in helping stop would-be opioid use disorder cases where many originate: with well-meaning doctors poised to write out a prescription. One such insurer is Pittsburgh-based Highmark, which is engaged in a multiyear partnership with a company called Wayspring to track providers’ prescribing habits and reach out to educate those who appear to deviate from the CDC’s recently updated clinical practice guidelines for prescribing opioids for pain.

For decades, a successful vaccine for respiratory syncytial virus (RSV) — which sends thousands of infants and older adults to the hospital each year — has remained elusive. Yet several heavyweight pharmaceutical companies are now poised to fill the void, as they’re nearing the finish line in the development of RSV vaccines that could ultimately comprise a multibillion-dollar market. Coverage of the new vaccines, according to an industry expert, will hinge on the all-important Advisory Committee on Immunization Practices (ACIP), which requires payers to fully reimburse any inoculation that it recommends.

Billing for remote patient monitoring (RPM) jumped by more than four times during the first year of the pandemic, according to a recent Health Affairs study. The increase was mostly driven by a handful of primary care providers. Using medical claims data from the OptumLabs Data Warehouse collected between Jan. 1, 2019 to March 31, 2021, the researchers found that there were 19,762 general RPM claims in March 2021, compared with 4,355 claims in February 2020. Continuous glucose monitoring, however, only saw a slight increase over the same period of time.

In addition, RPM claims were highly concentrated. The top 0.1% of primary care providers — identified by the researchers as “high-volume provider group” — accounted for 69% of all general RPM claims.

Humana Inc. will spend between $450 million and $550 million in debt and cash to gain full control of a group of primary care clinics that it launched with private equity firm Welsh, Carson, Anderson and Stowe (WCAS), and company executives said during the firm’s recent investor day that Humana plans to double down on its existing primary care M&A strategy. Health care finance experts tell AIS Health, a division of MMIT, that insurers’ spending spree on providers is only likely to accelerate, but that Humana is in pole position to benefit from deep investments in Medicare Advantage-focused primary care.

Health insurers have spent billions to acquire outpatient providers since the onset of the COVID-19 pandemic. Finance experts tell AIS Health that the spending spree has two sources of capital. Carriers are spending huge cash reserves taken in during the deepest parts of the pandemic, which saw utilization plummet as premium revenues increased. In addition, Wall Street is bullish on managed care: Lenders are lining up to offer generous terms to acquisition-hungry insurers, which have enjoyed strong stock performance since the start of the pandemic era.

Pharmacists and other non-physician care managers can improve the quality of diabetes care in the primary care setting, but structural issues make it difficult to fully leverage their potential, according to research published in the July issue of the journal Health Affairs.

“We need to have a different way of taking care of people with a chronic illness,” said Thomas Bodenheimer, a professor emeritus of family and community medicine at the University of California, San Francisco, who spoke at a Health Affairs briefing on July 19. The briefing convened several researchers who published diabetes-focused articles in the journal’s July issue.

In a series of articles in the July issue of the health policy journal Health Affairs, researchers evaluated diabetes care in the United States through several lenses, including care management, prevention, interventions, health equity, quality measures and value-based payment design. Several of them also spoke at a July 19 policy briefing in which a key message was that the fragmented U.S. health system is contributing to a plateau in improving diabetes care — and value-based diabetes payment programs may be causing still more fragmentation.

Despite remarkable advances in clinical understanding and treatments for diabetes, the U.S. has stagnated over the past decade in preventing and managing the condition, said Mohammed Ali, a professor in the Hubert Department of Global Health at Emory University. Ali served as the theme advisor for Health Affairs’ diabetes-focused issue and also was a co-author of the issue’s overview article, “Diabetes And The Fragmented State Of US Health Care And Policy.”

More employers are looking at offering near-site or onsite health clinics to employees and their families, in a bid to improve employee retention, elevate quality of care and better manage medical and pharmacy costs. To optimize these clinic offerings, employers should incorporate high-performing providers and align incentives between patients and primary care physicians (PCPs), say experts who spoke at a recent conference held by the Business Health Care Group (BHCG) of Wisconsin.

According to Mercer’s “Health & Benefit Strategies for 2023” report (see infographic), 17% of large employers said they currently provide onsite or near-site health services to employees, while 12% are planning or considering doing so. The survey was conducted April 26 to May 13, 2022, and included 451 organizations with 500 or more employees.