specialty pharmacy + medication assistance programs · case study. beaumont health overview •8...

Specialty Pharmacy + Medication

Assistance Programs

Presenters:

Scott Sterrett, PharmD

Manager, Specialty Pharmacy

Beaumont Health

FACULTY DISCLOSURE

The faculty reported the following financial relationships or

relationships to products or devices they or their

spouse/life partner have with commercial interests related

to the content of this CE activity:

- Scott Sterrett - Nothing to disclose

Who’s in the Audience?

IDN Pharmacy ExecutiveA.

Other IDN ExecutiveB.

Pharmaceutical IndustryC.

OtherD.

Tell Me About Your Site…

A. No specialty pharmacy (SP)

B. In process of developing/implementing SP

C. Well-established SP

D. Don’t know/not sure

Session Objectives

1. Detail the factors causing uncertainty and financial

hardship for pharmacy patients.

2. Identify three assistance programs that can help mitigate

these burdens.

3. Discuss the impact these programs have on patients and

providers.

What Are Specialty Drugs?

• High cost

• Treatment requires special monitoring

• Treats orphan, uncommon, or rare disease

• Special handling, storage, or distribution

• Limited distribution from manufacturer

• Treats disease already classified as specialty

• Requires patient administration training

EMD Serono Specialty Digest: 10th Edition (2014)

Specialty Spans Multiple Care Settings

• Route of Administration

–Oral and self-injectable

–Infusion centers

–Home infusion

• Insurance Coverage

–Prescription benefit

–Medical benefit

The Rising Cost of Specialty Medications

Peterson Kaiser Health System Tracker. Recent and

forecasted trends in prescription drug spending (2017)

Increased Cost-Sharing

• Specialty drug tiering

• High-deductible health plans

• Copay accumulators

Specialty Drug Tiering

76• % have specialty drugs in separate cost-sharing tiers

59• % have two or more specialty tiers

Median specialty copayment is $• 100

Average specialty copayment is $• 107

EMD Serono Specialty Digest: 10th Edition (2017)

The Rise of High-Deductible Health Plans

National Center For Health Statistics. National Health Interview Survey (2018)

HDHP Cost Sharing

EMD Serono Specialty Digest: 10th Edition (2017)

Copay Accumulators

• Manufacturer copay cards do not count toward

prescription deductible or out-of-pocket costs

• Many plans began adopting in 2018

• “Out of Pocket Protection Program”

• “Coupon Adjustment: Benefit Plan Protection Program”

Fein AJ. Drug Channels. http://www.drugchannels.net/2018/

01/copay-accumulators-costly-consequences.html

The Result…

Ease of Affording Prescription Medications

45%

28%

17%

9%

1%

Very Easy

Somewhat Easy

Somewhat Difficult

Very Difficult

Don't Have to Pay

Peterson Kaiser Health System Tracker. Recent and

forecasted trends in prescription drug spending (2017)

Financial Barriers Lower Adherence

• Globally1

–20-30% of prescription medications never filled

–50% of medications for chronic conditions taken incorrectly

• Medicare patients prescribed imatinib2

–32% failed to fill within 6 months

–Lack of low-income subsidy correlated with failure to start therapy

1Ann Intern Med 2012;157(11):785-95.2J Clin Oncol 2016;34(36):4323-28.

Financial Barriers Lower Adherence

• All insured patients who applied for copay asssistance3

–42% reported significant or catastrophic financial burden

–46% reduced spending on food and clothing

–46% used savings to defray out-of-pocket expenses

–20% took less than prescribed amount

–19% partially filled prescriptions

–24% avoided filling prescriptions entirely

3Oncologist 2013;18(4):381-90.

Types of Financial Assistance

Manufacturer1. -sponsored copay cards

Charitable foundations2.

Manufacturer3. -sponsored free drug programs

Drug replacement programs4.

Health system financial assistance5.

1. Copay Cards

• Manufacturer-sponsored

• Available for most medications

• Copay amount and maximum

benefit vary

• Generally no financial

requirements

• Cannot be used for federally-

insured patients

2. Charitable Foundations

• Available for many specialty disease states

• Eligibility and funding vary by program

• Patients with federally-funded insurance are eligible

• Examples

–CancerCare Co-Payment Assistance Foundation

–Chronic Disease Fund

–HealthWell Foundation

–Patient Access Network Foundation

3. Free Drug Programs

• Manufacturer-sponsored

• Need-based, generally

percent of FPL

• Require insurance denial or

proof of uninsured status

• Can be used for all patients

4. Drug Replacement

Manufacturer• -sponsored

Drug• -specific program

Pre• -administration vs. post-administration

May use for off• -label indications

Require insurance denial or proof of uninsured status•

Can be used for all patients•

5. Health System Financial Assistance

• Use as last resort

• Charity care/340B benefit

• Eligibility varies by system

Patient Benefits

• Increase access to medications

• Supports adherence

• Improved outcomes/disease management

• Reduced financial burden

Provider Benefits

• Better manage population health

• Decrease emergency visits/readmissions

• Decrease bad debt/charity care (maybe)

• Increase specialty pharmacy revenue

Medication Assistance Survey

Informal survey of Vizient Specialty Pharmacy listserv•

Assess types of assistance provided to patients receiving •

specialty medications

Seven responses from Academic Centers•

Vizient AMC Network Survey (2018)

7 7 7

6

MFG COPAY MFG FREE DRUG THIRD PARTY SYSTEM FUNDS

Vizient AMC Network Survey (2018)

What types of financial assistance

do you provide for specialty patients? (n=7)

What is the approximate percentage of

funds provided by each source (n=6)

58

28

15

MANUFACTURER CHARITY HEALTH SYSTEM

Vizient AMC Network Survey (2018)

For what medications do you provide

health system-sponsored funds? (n=6)

5 5

4

ORAL SELF-INJECTABLE INFUSED

Vizient AMC Network Survey (2018)

Have you seen a decrease in the amount of system-sponsored

funds since implementing your specialty pharmacy? (n=6)

3

2

1

YES NO UNSURE

Vizient AMC Network Survey (2018)

BEAUMONT HEALTH SPECIALTY

FINANCIAL ASSISTANCE

Case Study

Beaumont Health Overview

• 8 hospitals; 3,429 beds

• 5,000 physicians

• 187 outpatient sites

• 175,688 discharges (2017)

• $4.4 billion net revenue (2017)

• 5 infusion centers

• Specialty pharmacy

implemented 2014

Locations of Care

• Specialty Pharmacy

–Oral and self-injectable

–Serve employees, clinics,

and BH providers

–Pharmacy benefit claims

• Infusion Centers

–Infused therapies

–Variation in funding

assistance across sites

–No integration with SP

Specialty Pharmacy Assistance

• Staff

–2 dedicated Prior Authorization Technicians

–Comprehensive approach to medication access

• Types of Assistance Offered

–Manufacturer-sponsored copay cards and free drug

–Charitable organizations

Specialty Pharmacy Financial Assistance Secured

$1,142,780

$4,220,340

$2,654,288 $3,798,547

110

243

395

615

0

100

200

300

400

500

600

700

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

$4,500,000

2014 2015 2016 2017

Pat

ien

ts S

erv

ed

Ass

ista

nce

Se

cure

d

Over $11.8 million secured to-date

Infusion Center Assistance

• Relatively new process for infusion centers

• Primarily drug replacement and copay cards

• Troy Ambulatory Infusion Center (2017)

–$1.26 million worth of drug replacement

–$456,000 decrease in bad debt due to copay programs

Financial assistance touches the

lives of both patients and providers

Contact Information

Scott Sterrett, PharmD

Manager, Specialty Pharmacy

Beaumont Health

scott.sterrett@beaumont.org