Antidepressants for alcoholism, oral contraceptives for menstrual disorders, stimulants for weight loss; all of these are examples of off-label drug prescription use. It's a common practice, but is it safe or is it misuse or even abuse? The answer is, that depends.
There are three common myths circulating in the employer benefits marketplace regarding prior authorization (PA) services:
- All PA Programs are the same.
- My PBM won’t let me.
- It’s too confusing for members.
In this article, we’ll explore and dispel those myths and provide
a glance at the value of carving-out these programs from the pharmacy benefit management contract. Successful PA programs, when managed effectively, are the gatekeeper to controlling soaring pharmacy expenditures while ensuring the right patient gets the right drug in the right dose at the right time.
Topics: High Cost Medications, Controlling Pharmacy Expenditures, pharmacy spend, Coverage Determination Process, Prior Authorization, Specialty Drug Cost Control, Prior Authorization Processing, health plan management, population health, healthIT, data accessibility, patient outcomes,, drug costs,, rising drug costs,
Oncology management has evolved due to approval of new oncologic agents and their expensive costs. Previously, limited medication availability left practitioners with minimal options for cancer treatment. Newer cancer agents are designed to improve a patient’s quality of life and hopefully, overall outcome. With the rapid development of new oncologic medications, the management process has posed a challenge to physicians and payers. Providing oncologic medications in the most cost-effective manner requires cost-management strategies to weigh the benefits and risks.
Topics: High Cost Medications, pharmacy spend, Specialty Drug Cost Control, Specialty Drug, drug costs,, new cancer drugs, oncology medication, oncologic agents, FDA drug approvals, oncology, new oncology drugs
Over the past few years, prescription drug costs have risen in a dramatic fashion. According to a federal report released this spring, prescription-drug spending rose 12.6% in 2014 and spending is expected to rise 7.3% a year through 2018. The increased cost is most closely associated with the influx of specialty drugs—high-cost prescription medications used to treat complex, chronic conditions. Rather than offset these prices, generic drugs costs are also experiencing an increase in price adding to the prescription drug cost burden. Drug utilization and the increasing cost of prescription drugs for members who require these medications as maintenance therapy is constantly in the forefront of discussion.
Spending on specialty pharmaceuticals climbed 18 percent in 2015, compared to an increase of less than 1 percent for standard prescription medications. The burgeoning outlay comes as no surprise considering the hefty price tag of these new drugs, with some reaching upwards of $60,000 for a course of treatment.
HID had the honor of leading honored a Vision Session during the 5th Annual National Rx Drug Abuse & Heroin Summit that was held March 28-31 in Atlanta, Georgia.
Titled “Monitoring PDMP Effectiveness Now and in the Future,” HID’s presentation focused on how data accessibility and enhancement are effective tools for protecting public health and safety while supporting sound clinical prescribing, dispensing, and use of controlled substances. Attendees discovered:
- How collaborative partnerships support state PDMP goals and outcomes
- Why public and private health plans will require PDMP data
- How the ONC’s Interoperability Roadmap will change the way PDMP data is accessed
Program Manager Rebecca Poston, MPH, RPH, was on hand to speak on the tremendous success accomplished by E-FORCSE, the State of Florida’s PDMP. E-FORCSE has experienced real, tangible, positive outcomes since 2010 when the program began and HID’s RxSentry solution was implemented.
If you've missed this year's Summit, don't worry. Our team has provided the presentation slides and a brief recap after the jump!
It’s an inescapable truth that, in healthcare, data matters. For health information technology innovators, data is the window inside a lifecycle of a service, product, or application that can be analyzed for improvement. For providers, data helps the accuracy of diagnoses and creates more effective treatment paths. Health plans benefit from data as well. For plans, data builds actionable information and insights, two important steps in the balance of managing risk for each plan and enhancing outcomes for each member.
Health plans need access to information sources that help build for the future. But this need goes beyond simply connecting to the traditional repositories that capture and store large amounts of information. To optimize our understanding of users, patients, and members, plans must have access to sources beyond claims data. Expanded data sets from non-traditional sources will benefit plans with the right tools to manage collection and analysis.
One such non-traditional, underutilized source is prescription drug monitoring program (PDMP) data. Since the adoption PDMPs, these electronic database systems have amassed a decade’s worth of information regarding prescribing and dispensing behaviors of controlled substances as well as information that can be used to develop baselines for analysis or to monitor trends. There is an industry-wide need to make PDMP data accessible, building towards the goal of creating outcomes-based healthcare.
Building upon current frameworks of data sharing and utilization, we identify the opportunities in which PDMP data can help health plans in the future.
In recent years, the pharmaceutical industry has experienced slowing growth on a global scale, due in part to patent expirations, increasingly tough regulations and fierce competition from generics. One sector, however, has not suffered the same fate—specialty pharmacy.
Topics: High Cost Medications, Controlling Pharmacy Expenditures, pharmacy spend, orphan drugs, Meaningful Use, Coverage Determination Process, Prior Authorization, Specialty Drug Cost Control, Specialty Drug
ePA will continue to gain momentum.
Electronic Prior Authorization (ePA) is not going anywhere—and, we're not talking about the folks who test drinking water and lobby for reduction of air pollutants. There has been a lot of talk about ePA over the past year. In fact, Google records nearly 3.9 million results for the term and nearly every week there is a legislative update, industry news story, or forum on the topic. Don't expect that to change this year.
With benefit managers struggling under the weight of requirements from Federal rules like HIPAA, HITECH, and Meaningful Use, as well as State regulations, ePA has become an essential strategy for the evolution of pharmacy benefit programming and maintaining regulatory standards. However, the value of ePA reaches much further than compliance. ePA substantially increases efficiency in the continuum of care for everyone, including providers, dispensers, patients, health plans, and payors. Faxing forms is cumbersome and depends on old, outdated technology. With ePA, a determination can be received in just minutes, often times when the patient is still in the doctor's office. And, this value is what providers have been waiting for.
According to United Health Center for Health Reform and Modernization the United States spent $87 billion on specialty drugs in 2012, and that number is estimated to reach $400 billion by 2020. In 2014 alone the cost of specialty products alone has risen 13.1%. Specialty drugs now cost more than the median household income.