The rising costs of specialty drugs—often used to manage complex and chronic conditions such as cancer, autoimmune disorders and inflammatory diseases—are a pressing issue for employers due to their sky-high costs. Shockingly, specialty drugs, while representing only 2% of total claims, account for 50% of overall drug spending for most employers, creating financial challenges for employers that want to provide great benefits for their employees. To address this, employers must find ways to control costs and manage overall healthcare spending while ensuring their employees have access to necessary therapies without compromising patient outcomes.
Designing health benefits plans to ensure timely access to therapies
For many employers, a single specialty drug claim can wreak havoc on overall healthcare expenditures. Given the rising prices, determining the extent of specialty drug coverage is one of the biggest challenges facing employers. Accordingly, employers need to carefully evaluate which treatments to cover while keeping overall plan costs manageable.
Employers should explore benefit plan designs that focus on personalized treatment plans and ensure timely access to care. Rather than relying solely on traditional step therapy—which can delay access to optimal treatment and potentially lead to disease progression—collaborative approaches can often result in more effective treatments. By partnering with healthcare providers, healthcare consultants and specialty pharmacies, employers can ensure employees receive therapies based on their individual risk factors and disease severity, improving health outcomes while preventing costly complications.
Employers can further explore strategies to address the economic impact of inflammatory conditions, such as value-based care models and outcomes-based contracts with specialty pharmacies manufacturers, and providers. These approaches have the potential to align incentives and focus on achieving optimal patient outcomes. Data analytics and predictive modeling can also help identify high-risk employees and proactively manage their care, reducing the likelihood of costly complications. Additionally, fostering employee engagement and shared decision-making in treatment plans can improve adherence and overall treatment success.
Making informed coverage decisions and addressing hidden cost drivers
To ensure the long-term sustainability of health benefits plans, employers should evaluate their provider networks and pharmacy benefit management (PBM) contracts. Working with PBMs that offer competitive pricing, contract negotiation and rebate opportunities can significantly reduce costs, but you shouldn’t stop there.
Employers must be aware of hidden cost drivers by not independently managing your pharmacy benefit. An example of this is “dose creep,” which can significantly increase healthcare expenses. Dose creep occurs when the dosage of a specialty drug or truly any drug is increased beyond the standard of care for the majority of patients, leading to unnecessary costs. To prevent this, employers can implement utilization management protocols often managed independently of your PBM vendor that closely monitor the treatment, including drug dosage. Prospective reviews, prior authorization limits and independent clinical assessments can help ensure that employees are receiving the appropriate treatment for their condition without compromising care in an effective manner.
The role of employee education and independent oversight
Employee education and engagement play a crucial role in managing specialty drug costs and promoting overall wellbeing. When employees understand their healthcare options and the importance of adhering to prescribed treatments, they are more likely to make informed decisions that benefit their health and reduce unnecessary costs. Programs that focus on disease prevention, healthy lifestyles and chronic disease management can complement specialty drug therapies by reducing the overall incidence and severity of certain conditions. These programs need to be managed outside of the company profiting from dispensing a medication.
As the specialty drug market continues to evolve, employers must stay informed about the latest trends and innovations. The rise of biosimilars—biologic drugs that are highly similar to their reference products—offers a promising avenue for cost savings. Biosimilars have the potential to reduce the cost of treatments for chronic conditions, such as those managed by specialty drugs like Humira. Employers should consider integrating biosimilars into their benefits plans as a cost-effective alternative to higher-priced specialty drugs, but not all biosimilars are priced the same.
The rising cost of specialty drugs presents a significant challenge for employers, but with the right strategies it is possible to manage these costs while optimizing employee health outcomes. By designing health benefits plans that provide timely access to appropriate therapies, making informed coverage decisions, promoting employee education and engagement and addressing hidden cost drivers, employers can exert more control of their healthcare spend. Ultimately, a holistic approach to specialty drug management will benefit both employees and employers alike, fostering a healthier, more productive workforce.
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