Location, location, location (site of care really does matter)

Site of care doesn’t mean moving drugs from medical to the pharmacy benefit.

November 19, 2018

Autoimmune drugs dominate specialty spend

“This is where it all comes together.” Ramona Powell explained.

Ramona is director of specialty clinical program development for Prime. “Clinical, research, formulary, trade, benefit design, networks, reporting and analytics,” she lists them off on her fingers. “All of us come to the table. And all of us are thinking about how to make an impact for the individual patient with what we know.”

Ramona’s focus is the autoimmune category, which accounts for 14 percent of Prime’s drug spend, second only to diabetes in 2017. The autoimmune category includes dozens of conditions in which the body’s immune system attacks healthy cells. Common autoimmune conditions include rheumatoid arthritis, psoriasis and Crohn’s disease.

Three of the most popular autoimmune drugs accounted for nearly 10 percent of Prime’s pharmacy drug spend in 2017. And the category continues to grow.

Prime understands the inter-relationship between medical and pharmacy

Like so much of specialty, autoimmune drugs are often covered under the medical benefit. In fact, more than 25 percent of autoimmune specialty drug use is paid through the medical benefit.

That makes Prime’s unique connection to its Blue Cross and Blue Shield owners and clients so important. “We were one of the first PBMs to analyze both medical and pharmacy claims for autoimmune conditions, and then look at medical diagnosis codes to determine which drugs were used for which of the major autoimmune conditions,” Ramona said. Medical claim provider information and diagnosis coding can be used to categorize autoimmune drug use by indication.

“That analysis helped us develop aligned strategies to control the costs of autoimmune drugs and help improve outcomes – whether they are paid under the pharmacy or medical benefit,” Ramona explained.

Location makes all the difference in treatment costs

Ramona went on to explain: “Managing site of care (SOC) is a very effective strategy in the autoimmune category where drugs are often infused.” (Infused drugs are often billed under the medical benefit.) “For SOC savings, we help a plan develop and implement a SOC policy.”

An SOC policy doesn’t shift billing from the medical to the pharmacy benefit. Rather, it directs patients to the most cost-effective, clinically appropriate site of care, savings tens of thousands of dollars per patient, per year.

Prime’s SOC program targets patients currently getting their infusion services at a hospital facility, where infusion costs can be two to three times more expensive than other locations.

For example, one patient with Crohn’s disease received her Entyvio® via IV infusion at a hospital infusion setting. Helping this patient move her care to home infusion improved patient satisfaction and saved $45,000 a year.

Moving patients away from expensive sites of care could generate estimated savings of $1.41 PMPM.

Prime’s complete approach to SOC has the flexibility to create the right solution by plan and by condition.

In one Blue Plan, 40 percent of the SOC savings opportunities were from a large academic health system. Its contract didn’t allow SOC policies. Prime identified a system-owned home infusion service. The health system retained the members but still moved them to a different channel within the health system.

This minimized disruption to the health system and for members and generated savings of $1.41 PMPM.

Providing the right care, one patient at a time

Ramona knows someone with Crohn’s disease. “She’s had Crohn’s for many years and she still lives a full, vital life. She works full time, has a family and she’s active. I like to think that the work I do is helping people like her. Good research. The right care while helping contain costs. A focus on member experience. These things matter.”

Drug names are the property of their respective owners.

Prevalence and Cost of Autoimmune Specialty Drug Use by Indication in a 4.4 Million Member Commercially Insured Population Continuously Enrolled Four Years, 2012 to 2015 (Fall 2016)

Related news


May 20, 2024

Preventing opioid overdoses with naloxone

As prescription opioid overdoses rise in the U.S., the Prime/MRx Special Investigations Unit (SIU) shares how to identify if someone has overdosed and how you can help save a life


May 15, 2024

High-Cost Therapy Profile

Detailed information about Fidanacogene elaparvovec-dzkt Intravenous (IV)


May 15, 2024

June 2024 decisions expected from the FDA

Your monthly synopsis of new drugs expected to hit the market