Nearly half of specialty medications are billed under the medical benefit, where payers lack the rigorous cost controls that exist in the pharmacy benefit.
Specialty claims billed through the medical benefit tend to fall within three primary settings: in-home (10%), physician offices (46%), and outpatient facilities (42%). Outpatient facilities have proven to be the most costly site of care for patients, surmounting to nearly $1.2 billion across therapy classes in spend in 2015 alone.
Four Key Factors Driving Rate of Spend
The alarming rate of spend in this space is driven by a few cost influencers:
1. Wide Cost Variance: The price per medication in the medical benefit has a wide variability depending on the site of service, network rates, ability of health plan to apply claims management and additional costs for treatment of complex patients. In one case, Gammagard® (immune globulin intravenous) outpatient claims were three times more costly and came with 15 times higher administration costs as compared to in-home claims.
2. Hospital Purchasing Physician Practices: As doctor’s offices are purchased by hospital groups, it’s common to see a shift to a hospital outpatient setting, where reimbursement is much higher and drives up costs.
3. Duplicative Claims: Our analysis found claims processed under both the medical and pharmacy benefit for the same patient, similar drug, in close time proximity – indicating risk of waste.
4. Reimbursement Structures: Hospital reimbursement for nursing services and suppliers makes up large portion of overall spend and can include allowances for overhead costs. This is another element that makes outpatient facilities more costly than in-home settings where overhead is low and reimbursement is a nominal per diem or hourly rate.
All of these factors contribute to additional plan cost and complexity with no added benefit to the patient receiving the medication.
Controlling Costs Through Site of Care Solutions
Patients benefit from increased convenience and flexibility by moving to home service.
Our Medical Channel Management program redirects specific specialty medications from the medical benefit to the pharmacy benefit through utilization management where patients receive care from our specialist clinicians. Today, we have 110 clients, totaling 6 million lives, who achieve an average savings of 8-12% through this solution.
Home infusion, or Accredo Convenient Care, offers patients and plans the option to voluntarily redirect the administration of specialty drugs from high-cost sites of care like outpatient facilities to the home through outreach to patients and voluntary transition, where Accredo nursing support is available. One client launched Accredo Convenient Care reached out to 27 patients receiving infusions at outpatient facilities. By converting 15 of these patients to a more convenient in-home care, the plan saved $787,680 per year.
Our Medical Benefit Management program monitors drugs within the medical benefit when they cannot be moved to the pharmacy benefit. At Express Scripts, we have the ability to implement custom programs, where appropriate, in order to meet a client need to steer to a lower cost site of care.
comments powered by