Express Scripts' 2012 Drug Trend Report: Perspectives from Glen Stettin, MD

Pharmacy benefit manager Express Scripts has just released another drug trend report, and this year’s interactive offering provides a comprehensive look at utilization, pricing, and the top conditions for spend in specialty pharmacy.

Specialty Pharmacy Times spoke to Glen Stettin, MD, senior vice president, clinical, research and new solutions, about the major findings of the report, the efficiency of patient engagement, and how the proportion of total drug spend for specialty medications will change in the coming years.

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SPT: Your report found that the price gap between branded and generic medications is widening; the gap is the largest it has ever been since Express Scripts began calculating its Prescription Price Index in 2008. What are the implications of such a gap?

GS: Patients who choose to use a brand-name drug over a clinically equivalent generic are being charged a higher premium for this choice than ever before. This high cost affects both the patient and the plan sponsor.

SPT: New reports say that supermarket chain Wegmans is giving away generic atorvastatin for free. What does this pricing strategy (or lack thereof) say about the value of the pharmacist?

GS: Pharmacists are incredibly important to the health of the patients they serve. Such a strategy has nothing to do about the value of the pharmacist. Stores that price medication below their costs are simply stating that they are willing to lose money on this one medication in order to get more customers into their stores.

SPT: Overall spending on medications increased 2.7% as a result of increased spending on specialty drugs. Do you expect this trend to continue based on the number of biologics in the pipeline? Why or why not?

GS: We anticipate future prescription drug spending to increase at higher rates than the 2.7% we saw in 2012. More brand-name biologics are going to drive this increase, with less offsets from generics.

However, we have tools in place to help our clients mitigate the rising costs associated by these supply chain trends. For example, clients who take advantage of our utilization management programs are able to cut their pharmacy-related specialty drug trend in half. They’re getting great patient care, just without the waste.

SPT: In 2012, specialty conditions accounted for 24.5% of the country’s total drug spend within the pharmacy benefit—the highest percentage on record. Are you fairly confident that this percentage will increase as more specialty drugs become approved by the FDA?

GS: Yes. The proportion of total drug spend allocated toward specialty medications will continue to rise in the coming years. As we have shown, payers can mitigate this trend by applying proven utilization management techniques, as well as partnering with specialty pharmacies whose clinical model drives greater safety and less waste.

SPT: Will accelerated approvals by the FDA make it more difficult for health plans to get a handle on the increasing specialty spend?

GS: Specialty spend is a challenge for all health plans, and it’s not getting easier. However, we have solutions available to help them navigate this challenge. As a PBM, and a specialty pharmacy provider, we live and breathe this stuff. Unlike most health plans, we are staffed to track the day-to-day status of all the drugs in the pipeline. That gives us the ability to execute drug management strategies from the day these high cost drugs hit the market.

Clients who take advantage of our utilization management programs are able to halve their specialty drug trend that occurs within the pharmacy benefit. Using our medical benefit management programs, we are also able to apply these same proven tools to the specialty drug spending that occurs within the medical benefit. And we will continue to work with the federal and state governments to enable a more workable pathway for biosimilars in the U.S. market, which will also help stem rising costs.

SPT: Is increasing patient engagement a good strategy for achieving better health outcomes? Why or why not? Describe “choice architecture,” a term that was recently used by your Express Scripts colleagues in a recent Health Affairs article. What did they mean when they said that “sustained patient engagement conflicts with well-known cognitive limitations that are hallmarks of basic human nature”?

GS: Patient engagement is a good thing. However, our belief is that sustained patient engagement is incredibly difficult to achieve because it goes against the natural human tendency toward inattention and inertia. We are multi-taskers who have evolved an ability to focus for brief periods on topics that are pressing or pleasurable — and to let everything else function under the radar.

If the end goal is truly better health outcomes, a more effective way to get there is to re-engineer the system so that it facilitates better decisions, whether or not people are engaged. Many patients want to make healthier decisions, but due to inattention and inertia, they don’t always act on these good intentions. By using choice architecture techniques from the behavioral sciences, Express Scripts is achieving better health outcomes regardless of the patient’s level of engagement. One example of applying choice architecture is by asking patients to opt out instead of opting in to healthier behavior. Another is asking patients to pre-commit in the present to healthier decisions in the future.

SPT: What were the most surprising findings from the 2012 Express Scripts Drug Trend Report?

GS: For the first time on record, national spending on traditional prescription drugs decrease in 2012. The same core principles that led to this decline in traditional drug spending — for example, greater drug competition and the application of effective pharmacy benefit management tools – will be key to containing specialty drug spending in the future.

SPT: Do increases in the utilization of diabetes and attention-related medications say anything about the health of our nation?

GS: The ongoing obesity epidemic and aging of our population clearly contribute to the increased use of diabetes medications.

The use of attention-related medications is a different story — as a country, are we treating disease or medicalizing what is otherwise part of the spectrum of normal behavior?

SOURCE: Express Scripts, 2012 Drug Trend Report, released March 2013

SOURCE: Express Scripts, 2012 Drug Trend Report, released March 2013

SOURCE: Express Scripts, 2012 Drug Trend Report, released March 2013