A Breakdown of the 2012 Specialty Drug Benefit Report

69% of the employer groups studied in this report want more education on specialty pharmacy services.

A new report—the 2012 Specialty Drug Benefit Report from the Pharmacy Benefit Management Institute—recently shed some light on the goals of the players in the specialty market, as well as what employers and health care providers know (or don’t know) about the medical benefit.

The report was based on survey responses of 291 United States employers, health plans, and other related organizations, including employer coalitions, consultants, and pharmacy benefit managers (PBMs). The responses were organized by charts highlighting the trends in specialty pharmacy, with a particular focus on how they related to employers or health plans.

According to the report, the top priority for employers and health plans was reducing drug acquisition costs and reducing inappropriate utilization, respectively. Both groups mentioned overall cost when asked about their top concern regarding specialty drug medications for 2012. Additionally, nearly 50% of both employers and health plans pinpointed improvement of medication adherence as a top goal.

The most surprising section of the report dealt with the plan sponsors’ (or payers’) ability to track the specialty drug spend under the medical benefit. Eighty-five percent of plans and 88% of employers do not know how much they are spending in the specialty drug category under the medical benefit. According to the report, “less than 20% of health plans and employers currently are provided reporting from their PBM or other health care vendor on specialty utilization occurring on the medical side.”

Adam J. Fein, PhD, offered some explanations for this lack of medical benefit visibility on his Drug Channels website. He argued that the medical benefit is difficult to review for the following reasons:

• Medical claims are submitted in multiple formats (paper or electronic) and are not standardized like pharmacy adjudication systems.
• Claims are admitted after a service has been administered, not in real-time.
• Drugs are recorded using the Healthcare Common Procedure Coding System (HCPCS) J-Code, and some new drugs can go 12 months or more using a “not otherwise classified” (NOC) code, which does not give enough information about the product utilized.

Although there were many problems in specialty pharmacy benefit management noted throughout the report, nearly 70% of employers and 88% of health plans expressed an interest in knowing more about how to effectively manage this aspect of the plans. Other solutions outlined in the report included proposing a better cost-sharing model and integrating pharmacy and medical data under a more “active management of specialty pharmacy utilization under the medical benefit.”

To read about how a shift from the medical to pharmacy benefit coverage could potentially diminish the role of specialty distributors, see Dr. Fein’s article on Drug Channels.