Look for Prime + Magellan Rx at Asembia

Next week, more than 6,000 pharmacy industry professionals will gather at Asembia’s 2023 Specialty Pharmacy Summit, AXS23, in Las Vegas. Conference attendees representing the full spectrum of the pharmacy supply chain converge each year to build and expand upon essential business relationships that impact prescription fulfillment and delivery for millions of patients throughout the United States and beyond.

Recently, we connected with Prime Therapeutics’ (Prime) Nathan Downhour, senior vice president, health care services, who will serve as a featured presenter on May 2 at AXS23, to get his insights on today’s specialty pharmacy ecosystem and ways Prime and Magellan Rx together are transforming the industry with next-generation pharmacy solutions.

Prime: What’s something about Prime that more people should know?   
Nathan Downhour (ND): Delivery of specialty care to members is deeply personal to Prime. Some of us have been treated with specialty medications while many others have been a caregiver or relative or friend to someone who needs specialty medications. They often share stories about their experiences navigating this complicated path.

Those personal experiences affect us in our business decision-making. It’s part of what drives the North Star here at Prime — to be a people-centered partner, improving the experience for those we serve and transforming the health care landscape.

Prime: How is Prime helping clients and members benefit from treatment advances while managing costs?
ND: The number one question I hear from our clients is “What is Prime doing to control specialty spend?” And they mean total specialty spend, across both pharmacy and medical benefits. We do that in many ways, but there are a few I’d highlight.

HighTouchRx® looks at both medical and pharmacy claims using integrated data and predictive modeling. It identifies big savings opportunities on high-cost medications. In a case study for our vial optimization category, one of our clients generated $500,000 in annual savings.

Our NetResults formulary and utilization management (UM) programs deliver $10 to $25 per member per month (PMPM) savings and help optimize care.

GuidedHealth®, which offers a range of tools to help members and prescribers with medication regimens, can save up to $2 PMPM; it improves drug utilization, adherence and controls opioid use. Each of these programs also contribute to better clinical outcomes for members. Now, Magellan Rx gives us excellent new capabilities for managing medical specialty spend.

Prime: How does Prime’s approach with physicians differ from its direct competitors?   
ND: It’s quite different. We recognize the clinical value of the integrated pharmacy model.

Dispensing specialty medications to patients in the same ecosystem can improve physician insights into patient adherence and toxicity management while reducing waste. Our IntegratedRx® program does just that. It improves overall communication and coordination within the health care team. Others in the market have cut providers out of the equation by driving specialty prescriptions to their owned pharmacies, so physician and hospital-based specialty pharmacies aren’t able to provide these services directly to their patients.

Prime also has unique access to both medical and pharmacy claims due to our relationship with our Blue Plan clients. We use data mining and artificial intelligence to serve up actionable opportunities for providers to help improve the outcomes of their patients.

Prime: What’s next for Prime’s integration with physicians and how does that impact coordinated care?    
ND: For clients that don’t intend to pursue a robust physician employment strategy, Prime will partner with providers in other ways to create alignment. Coordinated care can be a broad topic. In the context of specialty pharmacy, it starts with enabling physician practices and health system-based specialty pharmacies to dispense specialty medications to the patients they serve in their clinics. We call this the integrated care model and it’s a core component of Prime’s specialty dispensing strategy.

If we’re going to improve affordability, patient experiences, and clinical outcomes in the specialty space we need to engage providers in our network strategy. But that needs to go well beyond dispensing. What’s next in our integration journey with physicians is an alignment model where we look to engage providers in sharing risk and sharing data. We need them to work collectively to drive results on the quadruple aim: lower costs, improved outcomes, great patient service and strong engagement with caregivers.

Prime: What trends do you foresee for the future in the specialty pharmacy industry or your area of responsibility?   
ND: Specialty pharmacy is evolving very quickly. The landscape will look much different over the next few years. We know our strategy must address the current market, but we need to be agile to rapidly respond to new innovations and market events, of which we will continue to see more.

For trends, we see cell and gene therapies that generate high one-time expenses up to $3 million per therapy. That demands creative ways to measure effectiveness and handle payments.

The rapidly changing environment for copay, accumulator, and specialty medication carve-out programs means member benefits and service programs may need to evolve in response.

The increase in biosimilars creates opportunities for cost optimization in the near term.

And everyone in the health care space will need to be extremely nimble to react to market events and to proactively innovate.

Nathan Downhour, senior vice president of health care services, joined Prime in 2021, bringing nearly two decades of specialty pharmacy experience. He currently oversees all clinical and specialty programs, trend management and strategic partnerships. In addition, he has worked to redefine the integration between pharmacy and medical benefit management to create a new, differentiated model for pharmacy benefit managers (PBMs).

More Prime and Magellan Rx experts will present at AXS23. Visit Prime’s newsroom for event listings.