Background: Specialty drugs are the fastest growing part of the pharmaceutical market, and this growth is expected to continue in the United States. As the specialty drug market continues to expand, questions regarding how to manage specialty drugs arise. One solution for the strategic management of specialty drugs is coordination and management across both the pharmacy benefit and the medical benefit. Study Goal: The goal of this study is to examine specialty drug and drug-related product distribution and utilization across the entire health benefit plan, and by therapeutic category in both the pharmacy and the medical benefit components of the University of Minnesota’s UPlan. The analysis will include identification of opportunities to coordinate and better manage safe and appropriate use of specialty medications while also managing the growth in expenditures.
Methods: The study design is a retrospective claims analysis. Claims data from the University of Minnesota’s UPlan pharmacy and medical benefits are evaluated from 2006 to 2014.
Results: There was a substantial growth in total specialty drug expenditures for the UPlan from 2006 to 2014. Specialty drugs and drug-related products accounted for a relatively small volume of claims with about 2 percent to 3 percent of all drugs and drug-related claims. In contrast, the percent of total drug expenditures accounted for by specialty drugs and drug-related products grew from 26 percent to 42 percent from 2006 to 2014. Over one-half of total specialty drug expenditures in 2014 were used to treat four conditions—multiple sclerosis, oncology, hepatitis C, and drugs for autoimmune diseases. The expenditures for total specialty drugs and drug-related products through the medical benefit more rapidly than expenditures under the pharmacy benefit. In 2013 and 2014, the top three sites of care identified under the medical benefit included physician’s office, outpatient hospital, and home settings. Thirty-five drugs were provided under both the pharmacy and medical benefits.
Implication: This study is timely and can help payers such as employer-sponsored health plans understand the full scope of the specialty drug expenditure and management landscape. A well-rounded picture of specialty drugs and drug-related product utilization trends over time is vital for effective management of employer-sponsored health plans. Additionally, identification of pharmacy and medical benefit overlaps in specialty drugs, drug-related product coverage, and drug distribution permits more effective management opportunities.
Conclusion: Expenditure tracking and claims level analysis are critical for appropriate evaluation and comparison of overall and specialty drug trends across pharmacy and medical benefits. Drug management strategies are needed that include both the pharmacy benefit and the medical benefit. A small number of therapeutic categories account for greater than 50% of total specialty expenditures. Specialty drug management needs to understand market trends and specific drug utilization and expenditures through detailed claims level analysis including overlaps in benefit coverage across the pharmacy and medical benefit. Data analysis can direct management strategies by identifying and facilitating a focus on drug utilization and expenditures driven by the top therapeutic categories.
University of Minnesota Ph.D. dissertation. May 2021. Major: Social and Administrative Pharmacy. Advisors: Stephen Schondelmeyer, Ronald Hadsall. 1 computer file (PDF); xv, 364 pages.
Specialty Drug and Drug-Related Products Management across The Pharmacy and Medical Benefit: Experience of A Self-Insured Employer from 2006 to 2014.
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