A Shifted National Focus Toward Specialty Meds

Jul 29, 2013
With U.S. spending on specialty medications increasing rapidly, Express Scripts is uniquely positioned to improve patient health and reduce pharmacy costs.
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The pharmacy landscape has reached a tipping point.

A decade ago, US prescription-drug spending focused largely on “traditional” conditions such as high cholesterol, high blood pressure and diabetes. These conditions are highly prevalent, and the brand-name drugs that treated them had become a major expense for employers and health plans. In contrast, “specialty” medications – those to treat more complex and rare conditions such as rheumatoid arthritis, multiple sclerosis and cancer – accounted for less than 10% of the country’s total drug spend.

This dynamic – traditional versus specialty – has changed rapidly in the last few years. Thanks to effective pharmacy benefit management and an unprecedented rise in generic drug availability, national spending on traditional medications fell for the first time last year. Meanwhile, spending on specialty medications has continued to increase 15-20% each year, an alarming trend that will persist in the future.

While only used by a small fraction of the US population, specialty medications now account for 24.5% of all pharmacy spend and by 2019 will account for more than half of all costs.  

Anticipated Annual Changes in US Spending On Specialty Drugs 

Why the Landscape Tipped

Over the past few years, a significant number of patents have expired for traditional brand-name medications. This opened the door for cost-effective generics, and the increased competition lowered overall traditional drug prices. Unfortunately, there are no such generic alternatives for many specialty medications, especially biologics. Although the Affordable Care Act allowed for a pathway for biosimilars – cost-effective generic alternatives for many specialty drugs – the industry is still awaiting clear guidance on how these drugs can enter the US market. As a result, drug manufacturers have focused their future R&D efforts on specialty medications, especially highly targeted treatments for rare conditions.

Uniquely Positioned to Lower Specialty Drug Costs and Improve Patient Care

While we continue to advocate for biosimilars as a tool to help rein in long-term specialty drug costs, Express Scripts is not standing still until that happens. We have solutions in place right now that deliver enhanced and more affordable patient care. In fact, clients that implement these solutions have seen their annual specialty drug spend increase at rates HALF as high as companies who do not implement these high-performing programs. They are receiving the same or better patient care – just without the waste.

Express Scripts and our specialty pharmacy, Accredo, are uniquely positioned to bring to market products focused on delivering the best-in-industry member care and trend management. Accredo provides wide national coverage with 30 pharmacy locations, broadest access to specialty drugs and best-in-class clinical support. Accredo also offers 440 specialist pharmacists and a nationwide nursing network consisting of 550 specially-trained nurses.

As we look ahead the next few years, here are just a few of our services that will be playing an increasingly important role for our clients and patients:

Medical Benefit Management. Because many specialty medications are administered in doctors' offices, clinics and hospitals, approximately half of all specialty medication spending occurs through the medical benefit. In these instances, payers have little insight into how patients are using these expensive medications and few opportunities to manage their use. Medical Benefit Management from Accredo provides comprehensive medication management tool across both the pharmacy and medical benefits for patients regardless of the site of care or disease state.

Therapeutic Resource Centers. The pharmacists and nurses in the Express Scripts Therapeutic Resource Centers (TRCs) have the disease-specific expertise and experience to provide patients with targeted clinical counseling to manage their conditions. The TRCs have visibility into each patient’s entire medication regimen and can fill critical gaps in care – ensuring patient safety and healthier outcomes, while also reducing costs for employers by cutting out waste from duplicate therapies, improper dosing and medication nonadherence.

Decision Support. Specialty medication regimens are complicated. Physicians must sift through a significant volume of data, and new treatments emerge frequently. As a result, many physicians find it challenging to keep updated with the latest information regarding therapy appropriateness, cost and other guidelines. Our decision support module allows oncologists to more easily adhere to clinical guidelines for the treatment of cancer by leveraging a library of over 1,700 evidence-based treatment regimens and 10,000 clinical trials for more than 120 cancer types. We expect that following these guidelines will help decrease unwarranted deviations from evidence-based medicine to drop from 35% to less than 10%.

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