Understanding pharmacy trend is important for developing robust, cost-saving specialty drug management strategies. But did you know you can’t really compare one trend number to another? Every PBM uses different methodologies, data sets, and calculations to arrive at their pharmacy trend number.

Additionally, one of the largest cost drivers of specialty spend today—prescriptions drugs dispensed through the medical benefit—is typically missing from pharmacy trend statistics. When you combine pharmacy benefit with medical benefit spend, you get what we like to call big ‘T’ Trend. In fact, you need to combine both to see there is as much, if not more, specialty spend going through the medical benefit today that is going unmanaged.

The ninth edition of the Magellan Rx Management Medical Pharmacy Trend Report includes a comprehensive medical pharmacy trend analysis and data benchmarking for provider-administered drugs which are infused or injected and paid under the medical benefit.

What are the top medical pharmacy trends you need to know to stay current with your organization’s management strategies?

1. Per-member-per-month (PMPM) spend on provider-administered drugs increased by 18% for commercial members in one year, reaching nearly $30 PMPM. The five-year trend is 68% — the highest jump in 9 years of reporting.
2. Across all lines of business (LOB), more than 90% of total drug spend on the medical benefit is being driven by a fraction of members who are taking specialty medications.
   
3. Emerging oncology treatments, particularly immunotherapy, are a major medical pharmacy trend driver. Keytruda had an impactful increase in utilization, with PMPM trend rising upwards of 200% and breaking into the top 15 drugs across all LOBs.
4. In Medicare, oncology and oncology-support drugs accounted for 58% ($30.17) of the medical benefit drug PMPM spend.
5. Chimeric antigen receptor (CAR) T cell gene therapies are predicted to grow 530% by the year 2022.
6. Factor products to treat hemophilia demonstrated the highest trend in both commercial (62%) and Medicare (185%), ranking #5 and #6, respectively. The average cost per claim is close to $20,000 across both LOBs.
7. Although 68% of payers are now using a site of service (SOS) program, SOS continues to be a concern with drugs administered in the hospital outpatient setting continuing to cost 2-3 times more than physician offices and home infusion.
8. When it comes to biosimilars, 64% of payers stated that the price of the biosimilar most impacted reimbursement decisions.
9. The top five drugs in commercial (Remicade, Neulasta, Rituxan, Herceptin, and Avastin) have remained consistent over the last nine years of reporting. However, all of these drugs have FDA-approved biosimilars that should all be available on the market in the next few months and, looking ahead, this landscape may look different over the next few years with this increased competition.
10. The number of billion-dollar drugs in 2017 was 34 and is projected to grow 26% to 43 drugs by 2022. All 43 are currently available on the market today, representing increased utilization and growth of these products in the next five years and reinforcing the need for proper utilization management, targeted dosing optimization and other management tactics of these high cost medical specialty drugs which will help to promote quality of care and prudent savings of healthcare dollars.

For more in-depth analysis on the latest in medical pharmacy trend and spend, watch our on-demand webinar!

Precision medicine describes an approach to treatment based on an individual patient’s unique genetic, environmental, and lifestyle factors. Genetic data, in particular, is central to the concept of precision medicine.

Perhaps more so than with any other disease state, precision medicine has had a definitive impact on the treatment of cancer. With the approval of imatinib (Gleevec®) to treat chronic myeloid leukemia (CML) nearly two decades ago, the concept of treating cancer based on underlying genetic anomalies was launched. In the case of CML, the underlying genetic abnormality is central to the diagnosis of the disease, but this is not the case for many other types of cancer. Specific genetic mutations may or may not be present in different patients with the same type of cancer. Identification of specific genetic mutations within cancer cells has led to the development and United States Food and Drug Administration approval of approximately 30 different “targeted” cancer treatments.

Tissue from the patient’s tumor is considered the gold standard for establishing the diagnosis and for identifying potential precision medicine targets. However, several challenges are associated with obtaining and interpreting information from tumor biopsies. Tumors may be located in areas of the body that are difficult to access and may require invasive procedures in order to obtain the needed tissue.

The use of liquid biopsies in place of tumor tissue biopsies is an emerging technology that may help to accelerate the use of precision medicine. The term liquid biopsy most commonly refers to the detection of tumor DNA fragments in the patient’s blood. This circulating tumor DNA (ctDNA) is the result of a dying cancer cell releasing fragments of DNA into the bloodstream. In addition to blood, liquid biopsies may also have utility with other bodily fluids, including urine, cerebrospinal fluid, and saliva, for example.

Liquid biopsies represent the potential for an easily retrievable source of information about a tumor’s genomic makeup, and they may have other advantages as well. Traditional tumor biopsies are often done on a single tumor lesion, which may inadvertently lead to sampling bias that does not capture the heterogeneity found in many tumors and/or different metastatic sites of the tumor. Conversely, ctDNA may provide a better “big picture” of the overall genetic makeup of the tumor cells. Another potential utility for liquid biopsies is the improved ability to monitor changes in the tumor’s genetic profile over time. Serial liquid biopsies can detect when a tumor acquires resistance to the current therapy before other manifestations of tumor progression are established. Liquid biopsies may also be able to spare patients more intensive treatments that offer limited added benefit. For example, in some types of cancers, the detection of microscopic residual disease remaining after surgery may identify patients who will benefit from further systemic therapy. Conversely, patients without this detectable residual disease by ctDNA may be spared from further toxic therapy that would not increase their chance of cure. TPerhaps the most hopeful use of ctDNA technology is the ability to screen and identify asymptomatic patients who are at a very early stage of their cancer when the possibility for cure is much higher.

For now, tumor tissue biopsies remain the standard of care in the majority of clinical situations; however, if the promise of liquid biopsies is validated through further study, more patients may be able to benefit from the promise of precision medicine.

In January, the Food and Drug Administration’s (FDA) Center for Drug Evaluation and Research (CDER) published Advancing Health through Innovation: 2018 New Drug Therapy Approvals. This report provides a benchmark for approvals and highlights the game-changers approved in 2018. Compared to 2016 and 2017, in which CDER approved 22 and 46 new drugs, respectively, in 2018 a total of 59 novel agents were approved. This number does not even include new and expanded uses of already approved drugs, new formulations, new dosage forms, or the seven biosimilar approvals. This marks the largest number of novel approvals in over two decades and far exceeds the average of 33 novel approvals per year in the past 10 years, surpassing the record setting approvals in 2017. Figure 1 outlines approvals and filings over the past 10 years.

Several potential explanations may account for this uptake in approvals in the past couple years. The FDA’s leadership, with its continued strategic initiatives, may be partly responsible for the increase. In early 2017, the FDA was criticized following the lower than average approvals seen in 2016. Public interest in opioid abuse and dependence treatment, access to drugs for rare diseases, drug shortages, and competition potentially affecting pricing have also put the FDA at the forefront of the public’s mind, further challenging the FDA to demonstrate action in the public’s interest. Finally, additional defined methodology for evaluating data in rare diseases, such as real-world and patient reported outcomes, may also have played a role.

Last year, all 59 novel drug approvals met their Prescription Drug User Fee Act (PDUFA) goal dates. In 2018, 32% were considered first-in-class and 58% were approved for rare diseases (Orphan Drugs). Priority Review was granted to 73% of new drugs, 7% received Accelerated Approval, 24% were designated as Breakthrough Therapy, and 41% garnered Fast Track designation. Furthermore, 95% were approved in the first review cycle, and 71% were approved in the US prior to approval in other countries. A breakdown of the types of drugs approved in 2018 is illustrated in Figure 2, with drugs in the expansive oncology spectrum once again dominating the approvals.

Some of the notable 2018 approvals included the first non-opioid drug approved to reduce opioid withdrawal symptoms, a new antiretroviral for multidrug resistant human immunodeficiency virus-1, a new class of drugs for migraine (calcitonin gene-related peptide receptor antagonists), the first FDA-approved drug derived from marijuana, the first treatment approved for multiple sclerosis in children, expanded options for cystic fibrosis, and the first antibiotic approved under the Limited Population Pathway for Antibacterial and Antifungal Drugs.

Among the several Orphan Drugs approvals were drugs for Fabry disease, phenylketonuria, X-linked hypophosphatemia, Lennox-Gastaut syndrome, Dravet syndrome, hemophagocytic lymphohistiocytosis, adenosine deaminase deficiency, and Lambert-Eaton myasthenic syndrome.

Although 2019 approvals have begun more slowly, given the substantial number of approvals in 2018, it appears that the large number of approvals from 2017 was not an anomaly but, perhaps, the continuation of a trend.

Note: The excerpt is from “How Work-Life Flow Is Shaping Success at Magellan”, first published here.

“People work best when they are happy and have the space to think and consider, to rest and recharge. Working shouldn’t mean missing out on some of those key family moments or having to struggle with responsibilities due to stress and exhaustion.

Working remotely means that there’s fewer interruptions, leading to greater productivity, happy customers and a happy team. That helps our customer satisfaction, our recruitment, our retention, and our bottom line. Our work-life flow is truly shaping our success. […]

[…]we’re proud to be at the forefront of offering flexible work options that allow work and life to flow for our professionals. So, naturally, we are honored to be named on the 2019 list of 100 Top Companies with Remote Jobs in 2019 by FlexJobs!“

Read more here…

One of the greatest challenges in managed care is staying up-to-date on the constantly evolving healthcare landscape. This can be especially overwhelming for high cost, complex specialty disease states. Payers are often faced with making difficult coverage decisions for hundreds of disease states as they also juggle prioritizing daily job tasks, such as managing drug spend, developing clinical programs and policies, and implementing member engagement strategies. In face of this challenge, payers have reported difficulties handling drug requests for complex treatments, particularly for off-label use for specialty drugs in high cost, rare disease categories, which are poorly understood and have limited clinical guidelines.

To address this unmet need, some payers seek the assistance of key opinion leaders (KOLs), also known as thought leaders. KOLs are considered experts in their respective fields, are regularly sought out by their colleagues for opinions or advice, are early adopters of new treatments or procedures, establish best practice protocols for patient care, and many managed care organizations depend on them to better understand specific disease states and new therapies.

As part of its value-based approach to medical and pharmacy benefit management, Magellan Rx Management has developed an Expert Clinical Network (ECN) of local, national, and world-renowned experts and has access to more than 120 key thought leaders in several disease categories, including rare disease such as hereditary angioedema, hemophilia, oncology, and more. These experts assist clients with challenging prior authorization case reviews, peer-to-peer discussions, drug policy development, and formulary guidance. Ultimately, the ECN offers health plans and providers the opportunity to make a more informed decision that leads to positive patient outcomes.

One case study from the ECN program was for a request from a client to review a complex prior authorization case. The request was for prophylaxis therapy in a patient who was currently using Firazyr for angioedema. The KOL provided an evidence-based recommendation based on patient’s medical history and current burden of disease. The KOL did not believe the patient was an appropriate candidate for prophylaxis therapy which resulted in the patient being referred to a center of excellence for additional evaluation and a potential cost avoidance of $44,000 per month.

As payers are faced with making difficult clinical coverage decisions for hundreds of disease states, assistance from a KOL can help in the reduction of inappropriate medication use, while offering the highest value and quality of care in disease management. To learn more download a copy of our MRx Report.

Specialty drug spend made up 41% of all drug spend ($318 billion) for the United States and European countries in 2017(1). New projections show specialty drugs will contribute to ALL of 2018 total drug spend growth due to a combination of explosive pharmacy trend in the specialty drug arena as well as declines in traditional medications(1). With thousands of specialty products in the pipeline expected to drive a significant portion of future medication costs and inflationary trends,(2) specialty growth has exceeded that of traditional drugs for the tenth consecutive year(1). Not only does specialty pharmacy trend continue to soar, these medications are now being created with remarkable biotechnology and gene-altering techniques to treat the most complex, high-cost healthcare conditions such as cancer, rheumatoid arthritis, and unique rare diseases.

Many of these specialty medications are billed under the medical benefit, which makes management even more challenging when considering complex medical benefit structures, numerous places of service, varied payment models, bundled claims, and complicated data.  Payers also cite several management concerns: determining the value of specialty drugs, ensuring clinically appropriate use, and responding to the specialty pipeline(3).

Spend trend and growing payer concerns emphasize the importance of developing strategies to stay ahead of the trend and pipeline. 

The Magellan Rx Management Medical Pharmacy Trend Report , in its ninth edition, includes a comprehensive view of medical pharmacy trends in claims data, including all major lines of business (commercial, Medicare, and Medicaid). According to the report, the 5-year pharmacy trend for specialty drugs on the medical benefit is 68%, 22%, and 17% (4) for Commercial, Medicare, and Medicaid lines of business, respectively. Driven by inflation, utilization, drug mix, and shifts in site of service, medical benefit drug spend has been identified as allowed amounts of $29.97 per-member-per-month (PMPM) for Commercial members, with Medicare PMPM allowed amounts of $52.19 (an increase of 18 and 12 percent, respectively, over the last year)(4). Yet visibility into this spend has been generally limited, given the management challenges addressed above.

It is critical for payers to stay current with evolving management strategies and marketplace conditions impacting medical pharmacy utilization and spend, especially as these specialty drug costs continue to be a leading driver of overall pharmacy trends. At Magellan Rx, we understand medical benefit drug spend, pharmacy trend, pipeline, and impact—all of which is imperative to formulating innovative, effective solutions for managing specialty drug costs. Get a more detailed analysis on the latest in pharmacy trends by signing up for our free webinar on March 14 at 1:00 pm Eastern.

1. IQVIA Institute 2018 and Beyond: Outlook and Turning Points. March 2018. Available at: https://www.iqvia.com/-/media/iqvia/pdfs/institute-reports/2018-and-beyond-outlook-and-turning-points.pdf
2. Commercial Specialty Medication Research: 2016 Benchmark Projections, Milliman Research Report. December 2015. Available at: http://us.milliman.com/uploadedFiles/insight/2016/commercial-specialty-medication-research.pdf
3. EMD Serono. Specialty Drug Digest 14th Edition. 2018
4. Magellan Rx Management. Medical Pharmacy Trend Report. 9th Edition. 2019. Available at: https://www1.magellanrx.com/magellan-rx/publications/medical-pharmacy-trend-report.aspx

Some people experience a serious mood change during the winter months, when there is less natural sunlight. This condition is called seasonal affective disorder (SAD). SAD is a type of depression, and usually lifts during spring and summer. Seasonal affective disorder impacts those who live in specific geographical areas, typically those who live in northern or southern hemispheres but is extremely rare in people who live close to the equator.1

SAD symptoms
SAD is a fairly common form of depression that occurs in the winter. During the winter days are shorter. Shortened days increase the chances of someone to develop SAD due to the lack of natural sunlight.

Common symptoms may include:

• Sad, anxious, or “empty” feelings
• Feeling hopeless
• Feeling guilty, worthless, or helpless
• Irritability and restlessness
• Loss of interest in activities
• Loss of energy
• Difficulty concentrating, remembering details and making decisions
• Difficulty falling sleeping or oversleeping
• Changes in weight
• Thoughts of death or suicide

Seasonal changes in bipolar disorder
In some people with bipolar disorder, spring and summer can bring on symptoms of mania or a less intense form of mania (hypomania). This is known as reverse seasonal affective disorder. Signs and symptoms of reverse seasonal affective disorder include:

• Persistently elevated mood
• Hyperactivity
• Agitation
• Unbridled enthusiasm out of proportion to the situation
• Rapid thoughts and speech

There are some measures you can take on your own that may help. You can make your environment brighter by sitting near windows and being exposed to more light. It is also helpful to get outdoors and be exposed to the sun and daylight. Regular exercise can help relieve the stress and anxiety brought on by SAD.

About 4 to 6 percent of people suffer from SAD and an additional 10 to 20 percent may suffer from mild SAD.2

Treatments SAD may be effectively treated with light therapy. But nearly half of people with SAD do not respond to light therapy alone. It is important to speak to your doctor about how you feel and determine the right treatment plan for you.

Here are a few tips on how you can manage SAD. Remember to speak with your doctor at any point about how you feel, and to determine the right treatment plan for you.

• Get enough sleep and practice good sleep habits
• Eat a healthy diet
• Try to exercise more often and find activities that make you happy
• Avoid alcohol and illegal drugs
• Talk with family and friends
• Stay active

When you are struggling with depression, talk about how you’re feeling to someone you trust. Try to be around people who are caring and positive. Volunteer or get involved in group activities.

People who have had repeated seasonal depression should talk to a mental health care professional about prevention methods. Starting treatment during the fall or early winter, before the symptoms of SAD begin, may be helpful.

For additional information, visit MagellanHealth.com/MYMH

1. www.mentalhealthamerica.net
2. American Family Physician, Seasonal Affective Disorder (www.aafp.org/afp/2000/0301/p1531.html) Source: National Alliance on Mental Health; National Alliance on Mental Illness (NAMI)

This document is for your information only. It is not meant to give medical advice. It should not be used to replace a visit with a provider. Magellan Health does not endorse other resources that may be mentioned here.

Reasons to tell people about it

Whether or not you discuss your condition with family, friends or coworkers is a personal decision. You may find it hard to talk about your diagnosis, or you may be concerned about how others will react. Ideally, the people around you will accept your illness and be encouraging. Bear in mind that they might not know very much about your condition. While they may want to help you, they may not know the best way to help. You can give them a better chance to support you by thinking ahead about how to tell them about your mental illness.

Why to tell
One reason to tell others about your mental illness is to receive encouragement. Talking to a sympathetic friend or loved one can reduce your stress level and improve your mood. You may no longer feel like you are keeping a secret. You may also want to ask for concrete support, like help finding treatment or rides to appointments. Or, maybe you want to share your crisis plan with a trusted family member.

When to tell
Telling people is a very personal decision and should only be done when you’re ready. It might help to practice how you tell people with a professional, such as a therapist. You can discuss your worries and how to react to issues, questions and comments that might arise. Practicing may help you clarify how you feel about your condition and inform who you want to tell.

Make sure you are in a calm environment when you introduce the topic and give the person time to adjust to the idea, especially if he or she don’t know a lot about your condition.

If you are compelled to tell people during a period where you are unwell, try to locate the most supportive person in your life for support as you go through the process.

Who to tell
You are the expert on your condition and can decide for yourself the right or wrong number of people to tell. Some people will benefit from telling many family and friends. Others may benefit by telling a couple of close friends and waiting to tell others.

Make a list of the people you’re considering telling and include those closest to you. Also list the most emotionally skilled people you know, even if you don’t know them that well.

Personal relationships
When telling family, friends or someone you are in a romantic relationship with about your condition, their response will generally go in one of three directions:

• The person is genuinely comfortable with your disclosure and things stay the same
• The person is very uncomfortable and ends or changes the relationship
• The person says he or she is fine with it, and then does a fast or slow fade from your life

Coworkers
In a job, you have to weigh the advantages against the disadvantages of being open. Weigh the potential negative impact on things like stigma from coworkers against your need for special accommodations, which are considered part of your civil rights. Before you share information about your condition, you should learn about your legal rights and also take into consideration your work environment. Consider approaching your Human Resources contact to gather support.

Once you’ve told someone, you’ll understandably be concerned about their reaction. One sign they can handle it is if they treat you the same during or after the disclosure. Friends stay friends. Colleagues stay polite and interested. If you continue to get the same “vibes” from people, you can be pretty sure that your disclosure has not changed the relationship for worse. And that is the best outcome of all.

Knowing that certain people are aware of an important part of your life and that they accept you and support you can be incredibly helpful and liberating. While some people may disappear, it’s better to have strong social supports around you.

Being able to offer emotional support is not something that everyone knows how to do. It’s a skill that takes practice. Some people may not be able to offer emotional support. If you have relatives or friends who lack this skill, that doesn’t mean they don’t love you. Most likely they don’t understand or fear they may say the wrong thing.

Remember that some conditions may cause you to not want to reach out for help. Sometimes the help from others is exactly what is needed to move toward recovery.

What to talk about
You can get the best support possible by planning the conversation. Consider including three items:

• “Process” talk
• Specific problem
• Suggestions for how loved ones can help

“Process” talk means “talking about talking,” rather than talking to share information. Prepare your listener for an important conversation by using “process” talk. Here are some ways to begin a process talk:

• “I want to talk to you about something important. I’m not sure how to talk about it, though. Can you just listen to me and try to understand? I’m hoping I’ll feel better after talking about it with someone, but I need you to be patient.”
• “There’s something going on in my life that’s bothering me. I think I need to talk to someone about it. I feel embarrassed about it, though, so please don’t laugh it off or make a joke out of it.”
• “I’m not sure if this will make sense. I feel uncomfortable talking about it, but I want to tell someone.

Concrete examples of what you mean by “mental illness.” Every case of mental illness is different. To get the best support possible, share one or two examples of what’s causing you stress:

• “I think something’s wrong because I can’t sleep more than a couple hours at night. It’s hurting my work and I feel out of control.”
• “I’ve started skipping classes sometimes. I’m worried I’ll stop leaving the apartment if I don’t get help.”
• “The doctor said I have bipolar disorder. Sometimes I feel like things are getting out of control and I’m not sure how to keep myself together.”

Suggest ways to support you. Family and friends may not know what they can do to help. You can get the best support by asking for specific types of help:

• “I’m scared to make an appointment because that’s like admitting there’s something wrong. But I need to see a doctor. Can you help me find one and follow through?”
• “I’m not thinking clearly these days. I’m getting treatment for a mental illness, but it might take a while to feel right. Until then, when I do something that makes you uncomfortable, can you please tell me what I’m doing instead of getting freaked out?”
• “I’m not supposed to drink alcohol with my medications. I’m going to try not to drink at parties, but I need my close friends to encourage me and help me keep my social life.”
• “I’m feeling better. But once in a while, can you tell me you’re there for me and give me a hug?”
• By telling the right people and suggesting ways for loved ones to help, you can start building a strong social support network. At first, you might be afraid to talk about your experiences. But don’t give up looking for support and encouragement from others. You’ll discover that many people want to help you.

You don’t have to share everything. Decide in advance what parts of your experience you’ll talk about and what parts you won’t. Stand by your decision. It’s perfectly understandable to answer a question with a statement like “I’d rather not talk about that right now.”

Keep in mind
Share the good things. Explain how your illness has taught you new things, or about experiences you were able to have in spite or, or because of, your illness.

Set boundaries. Be clear with people about when you want their advice and when you just want them to listen. Also realize that people come with their own opinions, informed and otherwise, so be patient when explaining. If they try to discredit you, gently remind them that you are the one living with the illness, and you know yourself best.

Let them know how they can support you. Everyone has different needs, and different people respond in different ways. Think about your needs ahead of time, and about whether this person can support you, if there are resources that would help her or him understand what you’re going through, or if she or he says no. Some people may not be able to handle disclosure, so it may be difficult to expect support from them. There are many people who will probably feel honored that you shared this with them, and whom will be happy to do what they can.

Help is available. For additional information, visit MagellanHealth.com/MYMH
Source: NAMI

This document is for your information only. It is not meant to give medical advice. It should not be used to replace a visit with a provider. Magellan Health does not endorse other resources that may be mentioned here.