Prime discusses strategies to cost mitigation

Pharmacy spend is growing year over year.¹ This spend is driven by novel therapies coming to market, increased utilization of medicines and higher list prices of drugs by pharmaceutical companies. Health plans and pharmacy benefit managers (PBMs) enlist cost mitigation strategies to help bring down spend and trend.

In the “Health Plan and PBM Cost Mitigation Strategies” webinar hosted by the Conference of Consulting Actuaries (CCA), Prime Therapeutics’ assistant vice president of health outcomes, Patrick Gleason, PharmD was joined by Kali Schweitzer, PharmD from Milliman and Ian Smith from OptumInsight in a session moderated by David Tuomala of Optum to discuss the industry landscape and approaches to cost savings.

Dr. Gleason shared that members who are “super spenders” (high drug cost claimants) and have more than $250,000 in annual drug spend account for 10% of all drug spend across both medical and pharmacy benefits. Thirty-two per 100,000 members fell into this super spender category last year – but that number is rising each year.² Because of their high spend, and their growth, Dr. Gleason said “focusing on drug management and reporting for savings opportunities” with this population is critical to driving down spend.

Prime’s Insights+ tool assists in identifying super spender members for potential intervention. In one model implemented by Prime and a health plan client, a PBM pharmacist embedded in the health plan worked to review opportunities and coordinate interventions with providers and members. These interventions included activities such as recommending to a provider to adjust dosing of a weight-based drug to save 15%, or switching to a lower cost generic hereditary angioedema drug that is equally as safe and efficacious for a 60% cost savings; interventions like these resulted in tens of thousands of dollars in avoided costs annually.

“Many of these very expensive therapies that drive up costs do not have competition within the drug class to lower unit cost,” said Dr. Gleason. “Nor do drugs – for the majority of rare orphan conditions – have impactful manufacturer rebates. All of this contributes to increased spend.”

Prime also built predictive modeling to help forecast which direction the super spenders are headed. “Are they going in the wrong direction – up? Or the right direction – down?” asked Dr. Gleason. Without integrated reporting and predictive modeling, it becomes even more difficult to identify future opportunities for cost mitigation to truly turn the trend on this cost growth.

“An integrated PBM and health plan, along with a high touch and thorough approach, are essential to get the cost mitigation success we’ve seen with our health plan clients,” said Dr. Gleason.

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1. The Use of Medicines in the U.S.: Spending and Usage Trends and Outlook to 2025. IQVIA.
2. Annual drug costs increased $1.25 billion for members with more than $250,000 in annual drug spend – doubling in four years. Prime Therapeutics.