Driving Out Waste in Cancer Care

Mar 8, 2016
When it comes to specialty drug management, active management of the drugs and the use of the best specialty pharmacy are critical in achieving great patient results and better savings.
Ashley Article

New research from Memorial Sloan Kettering Cancer Center found that many drug makers exclusively sell one-size-fits-all vials, particularly for oncology medications, which cause some patients to pay for medicine they are never actually given. Instead, these expensive drugs are administered to the patient and the remainder of the medication is discarded leading to $3 billion a year in waste.

How We Help

When it comes to specialty drug management, active management of the drugs and the use of the best specialty pharmacy are critical in achieving great patient results and better savings. Pharmacy Benefit Managers process drugs at the National Drug Code (NDC) level, which contains data not just about the drug and dose, but also the vial size. The medical benefit typically processes drugs using J-Codes and U-Codes, which include the drug name and dose, but not the vial size. When manufacturers make multiple vial sizes, Express Scripts’ systems will identify and limit reimbursement only for the most clinically appropriate and cost-effective vial size for each medication.

For example, one Accredo oncology patient was prescribed 900mg of Rituxan® (rituximab) – a medication only available in 500mg and 100mg vials – once weekly for four weeks. Many pharmacies would fill this prescription with two, 500mg vials, wasting 100mg of medication. However, our specialized clinicians recognized the opportunity to avoid wasteful dispensing while not increasing the expense to the patient.  Our pharmacy processed the prescription for one 500mg vial and four 100mg vials, saving 100mg and $753 per dose.

It’s important to take action on all types of waste so we can increase affordability, access and the financial headroom needed to sustain payment for even more innovative therapies in the future.

Solutions for Better Savings

Nearly 50% of all specialty drug spend and 80% of oncology drug spend is billed on the medical benefit, where payers lack the rigorous cost controls that exist in the pharmacy benefit. This causes inappropriate drug utilization, inaccurate billing and use of very expensive sites of care that create a tremendous amount of waste ($9 billion each year on specialty medications).

Express Scripts and Accredo have a long track record of managing medically billed drugs and a comprehensive set of tools to help achieve savings.

  • Medical Channel Management routes drugs from the medical side where utilization management and dose management programs are difficult to administer, and redirects them to the pharmacy benefit where patients receive care from our specialist clinicians. We currently have 36 Oncology drugs and 11 products for Blood Cell Deficiency in the program, with new products being evaluated each quarter. We have more than 5 million lives currently enrolled in this program, achieving an average of 8-12% savings from the rigorous Utilization Management and Therapy Management programs in place on the pharmacy benefit.
  • Medical Benefit Management monitors drugs within the medical benefit if they cannot be moved to pharmacy through utilization management, site of care, reimbursement management and oncology decision support. We can do the prior authorizations on the medical benefit, allowing those specific medications to receive the more precise adjudication that would reduce the potential for this sort of leftover waste. Our clients see an average of 10-15% savings with this program, and for one client this meant $1.9 million through claims management alone.

In addition, our Clinical Days’ Supply program uses evidence-based clinical and financial guidelines to determine optimal dispensing quantity by individual drug and individual patient. These specific guidelines eliminate waste and improve adherence for patients.

Express Scripts continues to work with to advocate on behalf of our clients and patients on issues that will help drive out waste in healthcare.

Specialized Care is Critical

Even more important than cost savings, Accredo’s 14-condition specific Specialty Therapeutic Resource Centers (TRCs) allow us to provide the most specialized care for patients with complex conditions. Our pharmacists and nurses spend 75-100% of their time in a primary area of specialty practice, developing a level of expertise, even by drug.

Our level of knowledge and specialization means we’re questioning, validating and optimizing every order as well as collaborating more effectively with the patient’s physician and plan sponsor to better care for the whole patient.

Within our oncology TRC alone, you’ll find the following unique features:

  • More than 200 patient care advocates, 80 specialist pharmacists and 60 nurses
  • Sub-specialized clinicians intensively trained in breast and ovarian cancers, prostate cancer, lung cancer, hematologic disorders and pediatric cancers
  • Nutrition counseling and access to TherapEase Cuisine, which offers the hands-on support of a board certified dietitian and individualized meal planning for better therapy outcomes
  • Social worker support, connecting patients to community resources
  • Proactive copay assistance for patients with copays over $50
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