Delivering specialty solutions with a patient-centered approach

“I was holding a vial in my hand worth more than $3,000, afraid to accidentally drop it, and it just hit me: this is what a patient with a specialty condition has to deal with every day,” recalled Sara Vande Walle, Prime’s specialty clinical program pharmacist for hereditary angioedema (HAE).

HAE is a rare, genetic condition that affects less than 400 of Prime’s 27 million members. Yet Prime’s clients spent $92.3 million on HAE treatment in 2017.

“I was a student on rotation at Children’s Hospital in St. Paul the first time I came across a patient with hereditary angioedema,” Sara said. “The patient’s parents brought the acute attack drug with them. Not only do these patients and families deal with a disease that can be life-threatening, they have to keep their medications with them at all times for situations like these.”

In 2015, Sara was in her third year in pharmacy school. Representatives from Prime came to one of her classes and did a presentation on research, formulary development and managed care pharmacy.

“I was hooked,” Sara says. She signed up for a five-week rotation at Prime. Then Sara was accepted into Prime’s one-year residency program, which rotated her through ten different departments. “I was lucky to have wonderful mentors during my residency. They supported me and challenged me to expand my skillset. I interacted with a lot of dynamic teams within Prime,” remembers Sara.

During Sara’s residency, she worked with Prime’s health outcomes team on a cost of care study on HAE. “I learned that most of our competitors are not looking at drug spend across both the medical and pharmacy benefits like we are,” she said.

Bringing the research to clients

In March 2018, Sara presented Prime’s integrated medical and pharmacy research on HAE to Blue Cross and Blue Shield medical and pharmacy directors.

“I think I was more excited than nervous,” Sara says. “This was research that Prime’s clients were really interested in. The audience was very receptive. More important, the discussion after the presentation added a lot of value.”

Some Blue Plans presented challenges and successes they have had with programs supporting members with HAE. Blue Cross & Blue Shield of Rhode Island has an embedded pharmacist program that has had success with one-on-one pharmacist case management.

In mid-2018, Sara stepped from the residency into an open position as Prime’s specialty clinical program pharmacist for HAE.

Research findings: outliers; new starts; key drugs

HAE is a complex and challenging condition to treat. It includes episodes of acute, potentially life-threatening swelling in different parts of the body.

• ~50 percent of drug spend is under the pharmacy benefit and ~50 percent of drug spend is under the medical benefit
  23 percent of members were new starts in the study period
  9 percent (outliers within the HAE group) had more than $1 million in HAE drug spend, accounting for 30 percent of Prime’s overall HAE spend
  Cinryze® and Firazyr®, injectable specialty drugs, make up 87 percent of HAE drug spend

Many Blue Plans considering pharmacist care

Prime’s recommendation for improving health outcomes and controlling costs is a high-touch pharmacist care program, assigned at the first fill of one of the HAE drugs. Prime presented an example of how pharmacist case management can work.

Member profile

• 62-year-old female
• Concurrent use of two acute HAE medications
• Drug 1: $694,909 billed on medical benefit
• Drug 2: $618,220 billed on pharmacy benefit
• No prophylactic HAE medications
• 30 hospital/ER visits in one year

Prime’s proposed interventions

• Limited use to one acute medication and started prophylactic medication to reduce number of attacks
• Helped identify triggers for attacks including environmental triggers, stress, medications, etc.
• Referred member to specialist and recommended mental health consultation

Prime case management could potentially reduce cost by 25 percent

A pharmacist care program that validates diagnosis (medical claims), confirms dosage and helps the member manage the use of multiple drugs could potentially save plans up to 25 percent of their HAE drug costs per year.

Looking at the whole patient

Producing groundbreaking research. Inspiring future leaders in managed care pharmacy. Fostering collaborative dialogue throughout the health care system. Improving health outcomes and managing the high costs of specialty drugs. As only Prime can do it.

“Our health care system is not good at looking at the whole patient,” Sara said. “I’d like to help build that.”