How can employers, providers and payers use value-based insurance design (VBID) to better manage specialty drug costs while enhancing care?
The answer: better care pathways to guide clinicians.
Prescribing a specialty drug does not have to be the automatic first step when a patient is diagnosed with conditions such as Hep C, RA, or Crohn’s disease. Insurance design can create care pathways that guide physicians in appropriate monitoring of certain chronic conditions in patients without symptoms and that meet certain criteria.
Prescribing a lower cost drug may be a more appropriate first step for other patients. That can help ensure that specialty drugs are prescribed only when medically necessary and create a more cost-effective care plan. It can also take into account the fact that high patient co-pays discourage utilization.
Take the scenario where a physician first diagnoses a patient with Hep C and considers prescribing one of the expensive new direct-acting antivirals (DAAs). In VBID, the care pathway may recommend that the physician first monitor the patient if a routine liver panel reveals that the disease is dormant and the patient has been living symptom-free for years.
Care pathways can also guide the choice of DAA, which avoid the side effects of interferon and have a better than 90% cure rate. Clinicians should select the DAA based on the virus genotype of the virus, the degree of liver fibrosis and any history of drug resistance. DAA side effects such as fatigue, headache, nausea, diarrhea, insomnia, itching and weakness can be taken into account in the protocol.
A PHM solution can help to easily identify patient populations that need ongoing monitoring, and facilitate outreach and monitoring to determine the efficacy of existing treatment regimens. Philips Wellcentive uses embedded guidelines for treatment options based on peer studies.
Physicians considering prescribing Remicade for RA, Crohn’s disease, or ulcerative colitis should first determine if the patient has any of a number of co-existing conditions, such as MS, Hepatitis B, heart failure, recurrent infections or compromised immune systems or TB. In these cases, the drug is contraindicated.