Trends in Managed Care

Inside Edge Consulting, Princeton

April 30, 2015

Earlier this month the Academy of Managed Care Pharmacists (AMCP) met in San Diego which afforded them the opportunity discuss and share information on the top trends in managed care. For those that follow managed care pharmacy, none of these will come as a surprise, but the following were the group’s main concerns:

  • Spending in specialty care and the future growth of this market
  • What to do about PCSK9s
  • How to move to a value based system and incent all stakeholders to make value based decisions

Below are highlights of topline thoughts on the topics above.

Spending in specialty care and the future growth of this market

In the next decade it is estimated that specialty drugs will account for approximately 80% of the spend — with only 1% of the patient population on a specialty drug. For managed care plans, this is unsustainable and they need to understand how to manage this spend. Standard PAs and step edits exist, but these are not considered long-term management for specialty drugs. This leads into the next topic area.

What to do about PCSK9s

There is an unmet need in lipid management, but the PCSK9s are expected to come with a hefty price tag. Both evolocumab and alirocumab will launch in the fall of 2015 with indications for patients with familial hypercholesterolemia. This is a concern for managed care, since a familial disease will likely impact multiple family members who will all need these medications. However, this is not the most substantial concern since the expected second indication for these agents is statin intolerant patients. Statin intolerance is hard to define and there are no clear guidelines on the definition. In addition, each of the two drugs launching had different criteria for determining statin intolerance. The number of statin intolerant patients could be in the millions, which means these drugs, if launched with a specialty price tag, could push health insurance plans over their budgets. While PAs and step edits can be used, they will not solve payers’ pricing concerns.

How to move to value based systems and to get everyone incented to make value based decisions

The first challenge with moving to value based decisions is the fact that data is not integrated or ready to be evaluated in this way; more time is required. There are many pilot studies and organizations looking into do this, but there is no one size fits all solution. To sustain the growth in the specialty area and the influx of patients into health systems, tools need to be developed to incent payers, patients, and providers to make value based decisions. This is not the first AMCP where we heard this and I doubt it will be the last until there is a concrete path forward.

Tyler Dunn
Senior Project Manager

AMCP, Cardiovascular disease, Consultant group, Health economics, Health outcomes, Healthcare, Healthcare consultants, Healthcare outlook, Lipids, Managed care, Oncology