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Preventing Leaks in Specialty Pharmacy

July 15, 2021 | Pharmacy

Prem Shah, Executive Vice President, Specialty and Product Innovation, CVS Health

Most of us know the feeling: one day, you hear the telltale sound of water dripping. You see a patch of damp wall which usually means one thing: one of your pipes has sprung a leak.

Then comes the call to the plumber, holes cut into the wall to repair the leak and then of course the clean-up. Problem fixed. But the fix can be costly, inconvenient and wasteful. Wouldn’t it be better to prevent the leak in the first place? What if you could run a test to let you know which pipe was likely to spring a leak before it happens?

While it may not be obvious, the discussion over fixing vs. preventing waste through leaks is not very different from how we think about effectively managing specialty pharmacy costs.

Specialty medications that treat rare and complex conditions are only used by a small percentage of any plan member population, and yet these medications make up more than half of all pharmacy spend. Our data show that specialty medications account for 52 percent of overall pharmacy spend driven, even though just 2.5 percent of plan members use them. This is because they generally cost much more than medications that treat other chronic conditions, and given their complexity, specialty conditions are typically more costly to manage overall.

We think the best way to control costs is by preventing “leaks” — eliminating unnecessary and wasted spend. This lowers costs while ensuring the best outcomes for our members. We know that the only way to stay ahead of rising costs is an integrated approach that utilizes a range of innovative strategies to identify potential leaks where member and payor money is being spent inefficiently.

CVS Specialty focuses on ensuring that the right therapies are used at the right time for the right member — helping control costs without sacrificing quality of care:

  • Ensuring clinical rigor through connectivity: We use our digital infrastructure and information derived from electronic health records (EHR) to validate treatment. We currently can connect with almost 70 percent of specialty patients, and nearly a third can be fully managed with EHR connectivity, including processing therapy referrals. This allows our specialty pharmacies to securely gather appropriate member information, including insurance, lab work and diagnosis codes which minimizes additional outreach to prescribers and reduces reliance on provider attestation. Our connectivity enables us to validate treatment without the need for additional prescriber outreach and ensures the appropriate medication is being used at the right time, starting therapy with certainty and preventing unnecessary spending. More aggressive utilization management (UM) practices, based around denying prior authorization requests are ineffective and often not rooted in clinical data and therefore maybe overturned — meaning these denials don’t deliver true lasting savings.

  • Eliminating wasteful spend through intelligent monitoring: With specialty therapies costing tens or hundreds of thousands of dollars, even relatively small amounts of waste can be significant. To prevent this, our automated surveillance can identify gaps in care and monitor efficacy, symptoms, pain and exacerbations. Given our high level of digital engagement. we can adapt our message to members and reach them through a channel of their preference. When appropriate, we can coordinate with providers to deliver targeted interventions, including stopping treatment or changing to a different therapy. Clinical interventions helped save about $2,000 per targeted member in a 90-day period, and following intervention, 23 percent of members stopped therapy or changed to another medication in the same timeframe. We also monitor for excess medication accumulation and adjust fill dates to ensure that members have the right amount of medication they need while reducing wasteful spend on oversupply.

  • Engaging and supporting members for better health outcomes: Total costs of care for members with rare and complex conditions is shown to be seven times more costly than the average member. Adhering to therapy, staying engaged with care and reducing adverse events can support lower costs. Our CVS Specialty patients have access to nurses and pharmacists who can answer questions about their medications, conditions, and side effects to help them adhere to their treatment plans. Additionally, our nurse-led care management program supports members at highest risk for adverse events. Taking this whole-person approach, we identify and engage with these members digitally, helping to manage care and understand their conditions and often complex care plans. Doing this, we can help improve clinical outcomes and avoid preventable downstream costs, such as emergency care or hospital admissions.

Our approach is not simply to be the plumber who can come in and stop a leak once it’s found — but constantly monitoring to and prevent potential leaks before they even become a problem.

This integrated specialty cost management model — starting therapy with certainty, eliminating waste and intervening as appropriate — offers the promise of cost savings while ensuring that members start and adhere to the most clinically appropriate therapies. This is all possible because of the investments in digital platforms and analytics, as well as our relationships across the health care system — creating an infrastructure that not only controls costs intelligently, durably but keeps members healthy.