Pharmaceutical Strategies Group Publishes Annual Plan Sponsors Report

Speakers at the AXS23 Conference in Las Vegas, Nevada, presented findings from a survey related to plan sponsors conducted by consulting firm Pharmaceutical Strategies Group (PSG).

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Genentech sponsored the survey, which was presented in a session titled “Plan Sponsor Speak: Viewpoints and Trends in Specialty Drug Benefit Design.”

The speakers from PSG included Morgan Lee, PhD, MPH, CPH, senior director of research and strategy; Mike Medel, PharmD, MBA, senior vice president of consulting; and Renee Rayburg, RPh, vice president of specialty clinical consulting.

The national survey was conducted online between September and October 2022. PSG conducts this survey annually, and many of the same questions were retained for comparison, while others were removed to make room for new questions that reflect the current pharmacy landscape.

The respondents were benefit leaders from 182 employers, union Taft-Hartley funds, and health plans, which represented approximately 86.7 million individuals.

The survey results showed that the top goals rated in the first position for respondents was management of overall specialty trend and specialty drug costs, management of total cost of care, and reduced inappropriate utilization.

It was also found that nearly all plans use prior authorizations, with 85% being able to track and report approvals and denials compared with 66% last year. Additionally, 14% were carving out 1 or more utilization management services for pharmacy benefit managers (PBMs), and 19% are considering it.

“There's a lot of things to think about for the aid your [pharmacy benefit manager (PBM)] needs to provide you right in the contract to be able to do that, and even if you have that right to be able to it doesn’t make financial sense,” Medel said during the presentation, adding that there are

financial impacts with prior authorizations.

Prior authorizations, when they have tighter criteria, equate to less of a drug out in the marketplace, he said.

The survey results also showed that 73% were aware of new market blocks before the survey, and 70% have plans that implement them.

For those that implemented them, 83% indicated they followed PBM standard recommendations, and 80% have criteria for medical exceptions.

“[Clients] would not use [new market blocks] if there was a drug that was approved for [a] life-threatening condition, but most of the time they're using it,” Rayburg said. “They’re increasingly willing to be a little bit more proactive in kind of controlling this process, making sure that they just don't have patients getting on these drugs without going through an appropriate use kind of evaluation, that type of thing.”

Approximately 81% of respondents think that gene therapies would be a major or moderate challenge for plan sponsors, and 24% said they had patients to date who used gene therapies.

Just 12% of plans participate in value-based contracting for specialty drugs.

The results showed that respondents said the elements missing to encourage organizations to use value-based pharmaceutical contracts included education and additional data or evidence; issues with agreeing on and tracking outcomes; lack of interest or buy in; lack of resources; low volume of individuals that the contracts would apply to; and resilience on external guidance from consultants or PBMs.

Finally, the survey results showed that 33% are exploring or using alternative funding, with employers more likely to use it at 14% compared with 7% of health plans.

When asked how sustainable they believed alternative fundings is, approximately 70% of respondents said that they are not or only slightly sustainable.

There are 2 lines of thought around the alternative funding programs, Rayburg said.

Some say that they feel the program is disruptive or delays the treatment for the patient, but there are payers that are using the programs that do not experience any hiccups, she said.

“It boils down to affordability for the employer. They are looking for every single nickel that they can find, because they see cell gene therapies coming out,” Medel said.

“They see all these things coming down the road, and they’re looking for kind of a lifeline or lever that they can pull, and this was one of them,” he said.

Reference

Medel M, Rayburg R, Lee M. Plan sponsors speak: viewpoints and trends in specialty drug benefit design. Presented at: AXS23 Conference. Las Vegas, NV. May 3, 2023.