Taking all factors into consideration

Molly Borchardt has dedicated her career in health care to helping people with hemophilia live the lives they want to live. She hopes that new products on the market will give people with hemophilia more freedom and flexibility.

Her commitment shows. You can hear it as she recalls her previous job at a national home infusion company. You can see it as she talks about coming to Prime and serving as a subject matter expert for hemophilia throughout Prime Enterprise Specialty.

She eagerly anticipates digging into a new role as clinical program manager for Blue Cross and Blue Shield of North Carolina.

“It’s near and dear to my heart,” Molly confessed. That’s good, because it’s been a big year for hemophilia.

Utilization is up and the drug mix is changing

Prime’s spending on hemophilia drugs rose 30 percent between 2015 and 2017. One reason for the increase is more people using more factor product. But the bigger reason for the increase is the shift toward higher-cost extended half life (EHL) factor product. At $600,000, the average annual cost of newer EHL factor products is more than twice that of standard half life (SHL) factor products.

Unexpected clinical results for members with hemophilia A

Factor is the clotting protein infused or injected to prevent bleeding. Today, the factor product category includes more than two dozen agents (with more in the pipeline). Members are moving towards the higher cost EHL products. The EHL factor product is supposed to last longer in the system, so ideally those members would use less factor. Do they?

A Prime study showed that members with hemophilia A who switched from SHL to EHL factor products used more factor product, not less. And because EHL factor product costs so much more, these members incurred costs that were 2.4 times as much as before. More factor and 2.4 times more cost? For members with hemophilia A in the study, mean annual cost for SHL went from $254,000 to $600,000 (2.4 times higher) with EHL factor product.

Four of five Prime members with hemophilia A still use SHL factor product. Spend across this category will double as more members switch to higher cost EHL therapies.

Members with hemophilia B did get some benefit from EHL factor product. They did use less product. Their costs still went up, but the amount of EHL factor product used went down.

“We met with the National Hemophilia Foundation (NHF) to discuss the study,” Molly said. “They were receptive to our findings and had some good input.” The NHF wondered if doctors even knew how much more these new drugs cost. The NHF also had some ideas for why patients might be using more factor product. Perhaps these members were not well controlled before. Or their doctors were working to target a higher level of control than before.”

Clients are cautious and customized criteria is needed

Molly presented the study’s findings to Prime’s Specialty Drug Strategy Committee. This group meets quarterly to connect Blue Plan medical and pharmacy directors with a cross functional team from Prime to discuss specialty drug management strategies.

“Overall, our clients are sensitive to management controls,” Molly explained. “But they were interested in the science. They could see costs doubling if we didn’t do anything. And as it stands now, they had a hard time seeing any benefit, any improved outcomes in exchange for letting members with hemophilia A move to EHL factor products.”

The discussions held shed further light on the findings and for a strategy going forward.

“We understand that there are limitations to our data. We can’t see into the doctor’s office or the patient’s home. We can identify and have open and frank discussions with other experts, like our plan’s pharmacy directors and the NHF. And then we can tie it all together.”

“The plans appreciated that we went the extra step to go outside to talk to the NHF for input,” she added.

Blue Plan clients asked that a prior authorization or utilization management (UM) program design include an override path for the doctor to get to the medication the member needed. Prime authored UM criteria the plans could use. Many plans customized it further, using Prime’s UM writers’ assistance because of the category’s complexity.

About one third of Prime’s Blue Plan clients now use UM for factor products.

Streamlining UM to meet specialty needs

Members with specialty conditions often cannot wait for any time lag that might be caused by UM. Molly and Prime’s clinical review unit identified a small group of pharmacists who would conduct all the UM reviews for hemophilia factor products. She provided those pharmacists with comprehensive training, giving them additional expertise in hemophilia UM. “They will be talking to providers and asking a lot of condition-specific clinical questions,” Molly said. “They will have flexibility to use their own clinical judgement.”

“If we can move just a few patients with this model, it will make a huge difference,” Molly said. “It adds up to millions of dollars so quickly.”

Molly is excited about her new role working closely with BCBSNC. BCBSNC recently implemented hemophilia UM criteria and is interested in doing a high touch model with one of their local hemophilia treatment centers in the future. It is also looking at a specialty pharmacy network, another important quality and savings strategy. Molly’s background will help a lot as they work to manage the trend in this category.

Molly says the integrated Blue + Prime model supports collaboration and innovation. “I enjoy that. Everybody wants to work together in the different departments at Prime. And we have really smart people at the Blue Plans we work with. We gain knowledge from them that helps set us apart.”