On the commercial side, health plans are required to provide coverage for children until the age of 26, and will be levied a new tax if they provide coverage for individuals and small businesses in Specialty pharmacies are going to have to find innovative ways to operate more effectively and efficiently, and be able to better demonstrate value to their payer customers if they want to be a contracted specialty pharmacy.
A: Pharmaceutical innovation is an area that can potentially suffer in the long run because of the ACA. The specialty drugs that are entering the market today have been in development for around 10 years, so the immediate effects of the ACA will not significantly impact new drugs coming to market in the next year or so, but will eventually start to have an impact over time.
The cost of innovation is primarily a function of drug development failures. Add to this the restrictions on how health care dollars are managed via the ACA, and there will come a point that manufacturers are not going to take the same investment risk they once did to develop and research innovative medication technologies because of so much uncertainty regarding any significant return on investment. The bill lacks effective provisions that are going to monitor and incentivize the development of new medication technologies.
If innovation is not going to be a high priority under the ACA, then neither quality nor medical resource efficiency can advance to improve the delivery of health care. July 26, Q: In your opinion, who should be responsible for paying for specialty medications?
Q: What is your viewpoint on specialty tiers? Q: In your opinion, what will ensure appropriate utilization of specialty drugs? Q: How do utilization methods like step therapy and day limits benefit the patient?
Effective engagement between patients and providers is critical for these drugs. Even more critical? A highly coordinated patient care approach, as these drugs may require that a patient, for example, adhere to a strict diet, take a course of other medications to manage additional conditions or side effects, and faithfully report progress back to their physician.
Value-based health models that align providers with total cost and care outcomes are appropriate tools for this category. A third category includes drugs used as needed for the episodic management of an acute condition such as cancer. These drugs are complex to manage. They generally must be administered on-site and are often tangled with moral and ethical considerations around patient preferences, quality of life, and life extension. Traditional management techniques, like prior authorization, are certainly necessary but unlikely to have a significant effect on spending unless applied before the patient begins a course of treatment.
The second category of drugs requires more complex management, integrating careful monitoring of the drug itself with numerous other healthcare and broader lifestyle facets necessary to ensure the drug accomplishes its goals and that adverse outcomes are avoided. But they also pose serious risks to individual payer and self-funded employer group economics, and the healthcare system at large if pricing strategies and cost management aren't effectively navigated.
The goal is nothing short of ensuring that the remarkable achievements of medical science benefit patients — without destroying the healthcare system that serves them along the way.
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RT CarenetHealth : "We have to get far more granular. In addition, Andy could obtain the drug from only one specialty pharmacy and would have to use mail order. These medications are becoming increasingly common, though many Americans are unfamiliar with the term.
In , the Food and Drug Administration approved 59 new medications , of which 39 are considered specialty drugs. They treat complex conditions such as cancer and multiple sclerosis. Specialty drugs are often available only through specialty pharmacies.
In addition to filling prescriptions, these outlets provide educational and support services to patients. For example, they provide refill reminders and help patients learn how to inject their drugs. In a forthcoming article , professor Isaac Buck and I argue that specialty drugs raise significant legal and ethical questions.
These merit attention from the public and policymakers. In addition, government authorities and medical experts are not the ones who decide whether a medication is designated a specialty drug. Rather, the decision is entirely up to pharmacy benefit managers , or PBMs. PBMs have been criticized for driving up health care costs. Drugs that are specialty drugs under one insurance policy are sometimes classified differently in other policies. Furthermore, some specialty drugs are simple pills that do not involve complicated instructions, and thus, it is unclear why they are categorized as specialty drugs.
The second problem is the very high cost of specialty drugs. Almost half of the dollars that Americans pay for medications are spent on specialty drugs. This leads to a situation in which you may have the least generous insurance coverage for your most expensive drugs.
Some specialty medications require special handling, monitoring or approval before they are prescribed. The drug manufacturers argue that biologic drugs are incredibly complex and sometimes impossible to replicate.
This distinction delays these medications from entering the market because pharmaceutical companies that create biosimilars need to prove that their products actually produce the same effects as the drug they are replicating, forcing them to fund case studies and tests with real patients. In the case of Gilenya and Tecfidera, used to treat MS flare-ups, competition in the specialty medication market can also actually drive costs up.
Patents are also an issue for generic drug advocates. According to the New York Times , while the main patent of Humira expired the end of , AbbVie, the company behind Humira, has amassed about 70 new patents covering the drug that could keep away biosimilars until Combining these drugs together creates a treatment therapy known as pre-exposure prophylactics or PrEP.
The manufacturer of Truvada, Gilead, owns U. While their patent for tenofovir expired late , their patent for emtricitabine does not expire until In our Artemis infographic , we discussed ways to avoid overspending on specialty medication. Some of these tips include:. All of these tactics require self-insured employers and benefits advisors to keep a close eye on employee benefits data. Employers and advisors should also work closely with Pharmacy Benefit Managers PBMs to get high-quality, accurate prescription claims data.
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