Market Access

Radar On Market Access: Highmark’s New Hemophilia Initiative Aims to Improve Care, Reduce Costs

December 11, 2019

With an eye on reducing spending and improving care among members with hemophilia, Highmark Inc. will launch a comprehensive program focused on the condition on Jan. 1. The health plan will partner exclusively with three companies — Option Care Health, Inc., Soleo Health and the Hemophilia Center of Western Pennsylvania — on the initiative, which has the potential to improve member care, reduce costs and cut down on fraud, waste and abuse, AIS Health reported.

With an eye on reducing spending and improving care among members with hemophilia, Highmark Inc. will launch a comprehensive program focused on the condition on Jan. 1. The health plan will partner exclusively with three companies — Option Care Health, Inc., Soleo Health and the Hemophilia Center of Western Pennsylvania — on the initiative, which has the potential to improve member care, reduce costs and cut down on fraud, waste and abuse, AIS Health reported.

Highmark chose hemophilia to focus on for a few reasons, says Sean Burke, manager of specialty pharmacy services at the plan. “We have a pretty comparatively high population” of people with hemophilia, and “clients were coming to us” for effective management strategies. New therapies — as well as a crowded pipeline — mean there is “a big opportunity to potentially save money.”

Of Highmark’s 4.5 million members, approximately 190 have a hemophilia diagnosis, and the health plan says it spends about $80 million annually on their care, with pharmacy costs making up about 90% of that.

The partners will be able to obtain the therapies at competitive rates, in large part because they “have more volume,” says Ned Finn, director of specialty pharmacy services at the insurer.

Highmark and the providers have performance guarantees and oversight protocols in place. Plan members not only will receive better care, but members and health plan clients will see potential cost savings of “15% or so,” says Burke.

“There are a number of guarantees,” Drew Walk, Soleo’s CEO, says, that are “focused on reducing waste and overall cost of care,” as well as “improving patient outcomes.…There are clinical and financial outcomes measurements.” Hemophilia is a “unique” condition which requires “monitoring individual patient response,” he notes. The key, he maintains, is to “not be too obtrusive” in management but to “intervene when necessary and provide a good patient experience. It’s more than just dispensing the product.”

If a product experiences a shortage or goes off the market temporarily, “we have direct lines of communication with the providers” to handle the situation, says Burke. “These pharmacies are very experienced with knowing how to handle this.”

MMIT Reality Check on Chronic Lymphocyctic Leukemia (Dec 2019)

December 6, 2019

According to our recent payer coverage analysis for chronic lymphocyctic leukemia (CLL) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for chronic lymphocyctic leukemia (CLL) treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for CLL treatments shows that under the pharmacy benefit, almost 48% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: The FDA has approved two biosimilars for Biogen and Genentech’s Rituxan (rituximab), and both are indicated for CLL. Teva Pharmaceuticals USA, Inc. and Celltrion, Inc.’s Truxima (rituximab-abbs) launched in November 2019, and Pfizer Inc.’s Ruxience (rituximab-pvvr), approved in July 2019, will launch in January 2020.

Radar On Market Access: New Acute Migraine Medications May Not Shake Up Formularies

December 5, 2019

New oral medications for acute migraine — one pending launch and two more that could be approved in the coming months — likely won’t shake up formulary coverage for a condition that’s largely treated by generic triptan medications, pharmacy benefit experts tell AIS Health.

New oral medications for acute migraine — one pending launch and two more that could be approved in the coming months — likely won’t shake up formulary coverage for a condition that’s largely treated by generic triptan medications, pharmacy benefit experts tell AIS Health.

Eli Lilly and Co. on Oct. 11 received FDA approval for its drug Reyvow (lasmiditan), an oral medication that’s the first serotonin (5-HT)1F receptor agonist to be approved for migraine. Meanwhile, Allergan on Nov. 19 said it’s on track for December FDA consideration of ubrogepant, an oral CGRP receptor antagonist for acute migraine. Biohaven Pharmaceuticals also has applied for FDA approval on its oral CGRP antagonist rimegepant.

Mesfin Tegenu, R.Ph., president of PerformRx, doesn’t expect widespread uptake of Reyvow. “The launch of lasmiditan will likely not change the formulary status quo when it hits the market, as it most likely will become a niche medication for patients inadequately controlled on triptans, or for those who cannot take triptans,” Tegenu tells AIS Health. “This is primarily due to warnings on the label for driving impairment and central nervous system depression.”

PBMs could have the chance to consider how to handle Reyvow and ubrogepant soon, although it’s not clear how soon. Eli Lilly hasn’t yet set a launch date for Reyvow, while Allergan said it expects ubrogepant to be the first approved oral CGRP receptor antagonist for the acute treatment of migraine.

“As with any new product, [ubrogepant] will need to be analyzed as part of the class of drugs for this indication,” Tegenu says. “Since this is the first oral version of a CGRP antagonist, it does have some administration advantages over injectable products.”

Payers can implement utilization management programs that direct use of these new drugs to those who have failed or cannot tolerate triptans, says Nicole Kjesbo, principal clinical program pharmacist with Prime Therapeutics LLC. “Additionally, payers will consider exclusion strategies and potentially value-based contracts as a means to manage cost and appropriate therapy,” she says.

MMIT Reality Check on Crohn’s Disease (Nov 2019)

November 29, 2019

According to our recent payer coverage analysis for Crohn’s disease treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for Crohn’s disease treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for Crohn’s disease treatments shows that under the pharmacy benefit, almost 58% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In July 2019, the FDA approved Samsung Bioepis Co., Ltd.’s Hadlima (adalimumab-bwwd) for the treatment of rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, adult Crohn’s disease, ulcerative colitis and plaque psoriasis. Merck & Co., Inc. will commercialize the drug in the U.S. It is expected to launch after June 30, 2023.

Perspectives on Racial Bias in Optum Risk-Prediction Algorithm

November 28, 2019

To improve care for patients with the most complex health needs, many providers and payers turn to risk-prediction tools that use an algorithm to determine which patients need more intense care management. But a recent study, published in the journal Science, found that one such widely used algorithm exhibits significant racial bias by assigning black patients the same level of risk as white patients even when they are far sicker, AIS Health reported.

To improve care for patients with the most complex health needs, many providers and payers turn to risk-prediction tools that use an algorithm to determine which patients need more intense care management. But a recent study, published in the journal Science, found that one such widely used algorithm exhibits significant racial bias by assigning black patients the same level of risk as white patients even when they are far sicker, AIS Health reported.

This study garnered significant media attention, and at least one state’s regulators launched an investigation into UnitedHealth Group, whose Optum subsidiary sells Impact Pro, the data analytics program that researchers studied.

Brian Powers, M.D., one of the study’s authors and a researcher at Brigham and Women’s Hospital, says that “the algorithm did a great job of what it was specifically designed to do, which was predict future health care costs.” The problem is that the organizations deploying the tool often “use health care costs as a proxy for health care need,” he says, and black patients tend to cost the health system less because of a “lack of access to care due to structural inequalities, and a variety of other issues that have been well documented.” So while there is a correlation between high-risk patients and high health care spending, just looking at expenditures doesn’t paint a truly accurate picture of patients’ health care needs.

Rich Caruana, a Microsoft Corp. senior researcher who studies machine learning in health care, says he was “not at all surprised” to learn that researchers uncovered hidden bias in a predictive algorithm.

“Most of what machine learning is doing is right, but in addition to these things it’s doing really right, roughly 5% of what it’s learning are these sort of silly, wrong things,” he continues. “These are known as treatment effects — we’re seeing patients’ risk as more or less based on the treatment that they receive.”

MMIT Reality Check on Atopic Dermatitis (Nov 2019)

November 22, 2019

According to our recent payer coverage analysis for atopic dermatitis treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

According to our recent payer coverage analysis for atopic dermatitis treatments, combined with news from key healthcare influencers, market access is shifting in this drug landscape.

To help make sense of this new research, MMIT’s team of experts analyzes the data and summarizes the key findings for you. The following are brief highlights. To read the full piece, including payer coverage, drug competition and prescriber trends, click here.

Payer Coverage: A review of market access for atopic dermatitis treatments shows that under the pharmacy benefit, about 26% of the lives under commercial formularies are covered with utilization management restrictions.

Trends: In March 2019, the FDA expanded the approval of Dupixent (dupilumab) to treat moderate-to-severe atopic dermatitis in people aged 12 to 17 years whose disease is not adequately controlled with topical prescription therapies or when those treatments are not advisable.