Primary care providers can be responsible for everything from first line dermatology to behavioral health to musculoskeletal injuries. In a world of rapidly changing technologies, and in which new therapies can cure or alter diseases that only a few years ago would have never been thought possible, the basics still matter. As a clinician, I’ve practiced internal medicine and psychiatry, and still have the opportunity to work with a FQHC in building integrated care. Those experiences and my national view of utilization and prescribing patterns highlight the need for provider support to care for persons with mental health conditions, including opioid use and abuse.

It is often challenging to translate new medical knowledge to the clinic setting. How does a provider care for the individual on a potentially lethal combination of opioids, benzodiazepines, and muscle relaxants? Or, how does one address the young child who has been placed on a combination of psychotropic medications.

In our current health system, primary care providers are in the best place to begin patient care journey or change the course of an already established treatment plan. An effective solution for supporting providers in delivering high quality care is in the form of provider support, especially through programs that involve data analytics, followed by one on one academic detailing. PBMs are in a unique position, having the ability to assist providers in working with patients on complex behavioral health or opioid regimens. PBMs have access to data that allows for identifying outlier member and provider behavior and finding patients who are at risk for adverse outcomes. While PBMs don’t have access to prescription drug monitoring programs, they can see what prescriptions are filled, where there is overlap, and where there are multiple providers interacting with a patient.

Magellan Rx developed the Live Vibrantly: Whole Health program to address those outlier providers and members, with the goal of achieving higher quality care. This program uses evidence-based algorithms to find members who may be at risk for adverse outcomes, and targets prescribers who may be over-prescribing. We become the provider’s go-to source for translating the evidence to the bedside through assistance with difficult issues, such as withdrawing an individual from high dose opioids. Through taking an approach to support providers in delivering high quality care, we’ve been able to truly partner in leading our members to leading more healthy vibrant lives.

More than 400 nationally-recognized payers, physicians, and industry insiders came together to share thoughts and insights on the ever-evolving specialty drug landscape at the 16^th annual 2019 Magellan Rx Management Specialty Summit hosted August 26-28 in New York City.

As the specialty drug trend continues to rise (especially on the medical benefit) and the pipeline continues to expand, focusing on management strategies and solutions is key. With biosimilars flooding the market and capturing the headlines, and looming policy updates creating uncertainty, this year’s event was a platform to tackle these critical topics and the future of our industry.

“We’re honored to be the forum that brings people together to share insights, engage in thoughtful debate, so that we can all walk away with actionable solutions to effectively manage this growing specialty drug trend.” –Steve Cutts, senior vice president & general manager, specialty, Magellan Rx Management

Highlights from this year’s program include:

• Dr. Peter Bach of the Memorial Sloan Kettering Cancer Center reviewed the latest developments for better oncology management and Dr. Rafael Fonseca, a Mayo Clinic Distinguished Investigator, examined applications for a more personalized approach to treatment for complex specialty conditions.
• Magellan Rx chief medical officer Dr. Caroline Carney was joined by Sarah K. Emond, executive vice president and chief operating officer of the Institute for Clinical and Economic Review (ICER), in a fireside chat about ICER’s approach to health policy and excellence in the U.S.
• Mostafa Kamal, CEO of Magellan Rx, led a panel of forward-thinking innovators who are disrupting the status quo by providing tech-based solutions to improve healthcare delivery and outcomes: Raj Agarwal, chief executive officer at Medocity; Adam Hanina, chief executive officer at AiCure; and Richard Waithe, president of VUCA Health.
• Several panel discussions highlighted next-level management strategies around medical pharmacy solutions as well as emerging therapies like CAR-T and other gene therapies to treat rare and orphan diseases, and featured a diverse group of speakers including executives from national and regional payers, pharmaceutical manufacturers, and physicians:
  • Martin Burruano, RPh, Vice President, Pharmacy Services, Independent Health
  • Mona Chitre, PharmD, CGP, Chief Pharmacy Officer & Vice President Clinical Analytics, Strategy & Innovation, Excellus BlueCross BlueShield
  • Kim Dornbrook-Lavender, PharmD, BCPS, Director, Clinical Pharmacy, Medica
  • Pat Gill, RPh, Director of Pharmacy Programs, Horizon BCBCS of NJ
  • Doug Long, Vice President, Industry Relations, IQVIA
  • Joseph Nolan, General Manager – US, AveXis, Inc.
  • Helio Pedro, MD, Clinical Geneticist, Hackensack Meridian Health
  • Carly Rodriguez, PharmD, Pharmacy Director, Clinical Innovation, Moda Health
  • Natalie Tate, PharmD, MBA, BCPS, Vice President, Pharmacy Management, BlueCross BlueShield Tennessee
• Industry experts Claire Wulf Winiarek, Beth Hebert-Silvia (VP & Practice Lead, Health Plans at Pharmaceutical Strategies Group) and Michael McCaughan (founding member of Prevision Policy LLC) shared their insights on the current policy landscape.
• TV personality and author Janice Dean graced the audience with her very own patient story—after receiving a Multiple Sclerosis diagnosis in 2005, she underwent treatment and found hope and a passion for sharing her story to encourage others who are living with MS to live their best lives as well.
• Keynote speaker Keller Rinaudo shared his incredible story of perseverance that led to the launch of a revolutionary healthcare startup, Zipline, that is rapidly changing the face of medicine in remote parts of the world—and future expansion for U.S. disruption.

As pioneers in specialty pharmacy management since 2005, Magellan Rx has been leading the conversation around better management strategies that not only provide cost savings for payers but positively impact patient health outcomes. Each year, we develop the Specialty Summit agenda with those values in mind. Mark your calendars and join us next year in NYC on August 24-26, 2020 as we host another event that will ignite inspiration and innovation across the industry.

With the number of opioid-related overdose deaths in the U.S. reaching a record high last year, it’s time for our nation to fully embrace evidence-based treatment options that best support our communities, loved ones, friends and families in their recovery efforts.

One growing approach—often considered as the gold standard of treatment—is medication-assisted treatment (MAT). MAT is the use of FDA-approved medications in combination with counseling and behavioral therapies to provide a holistic, person-centered approach to the treatment of substance use disorders (SUDs). The use of this treatment approach has grown to nearly 40 percent in residential facilities and is increasingly leveraged by primary care providers nationwide—but more still must be done for widespread adoption.

The most pervasive stigma surrounding MAT is that it merely enables patients to replace one addiction with another. It’s a belief held not only by some groups of doctors and clinicians, but also family members and peer support groups—those whose support is critical to successful recovery. When a patient’s core support system of family members and peers doubts the legitimacy of an evidence-based form of treatment, the likelihood that the patient will follow through long-term is diminished.

Pair that with a lack of understanding and comfort from the medical community around how to administer MAT, limited numbers of physicians who are certified to prescribe this treatment that actually do prescribe the treatment, as well as the number of residential facilities that offer MAT, and we get low adoption rates as a result of these barriers.

There’s a better way to treat opioid use disorder

Although abstinence-based therapy works for a small percentage of those suffering from OUD, MAT offers a successful way for people to fight their addictions in an outpatient environment, in the community in which they live, and avoid hospitalization or institutionalization. It helps those struggling with OUD and other SUDs address underlying conditions that may have contributed to substance abuse—significantly improving the chances of recovery. In one study, more than half of patients utilizing MAT reported opioid abstinence 18 months after beginning treatment.

Today, while 900,000 U.S. physicians prescribe opioids, fewer than 35,000 physicians are certified to prescribe buprenorphine, one of three medications approved to treat opioid addiction. And even fewer actually prescribe buprenorphine to patients. MAT prescribing is not limited to psychiatrists. In fact, primary care providers provide more access to MAT than any other type of provider.

The impact of limited access to MAT on health outcomes cannot be overlooked. One analysis found only one-third of individuals who experienced a nonfatal opioid overdose received access to MAT. Those who received methadone were linked to a 59 percent decrease in mortality rates after one year, according to the analysis. Additionally, individuals who were treated with buprenorphine were associated with a 38 percent decrease in mortality after a year.

Increasing Access to MAT

The SUPPORT for Patients and Communities Act, signed in October 2018, expands the ability to prescribe MAT by increasing clinician eligibility for certification. This provision is a solid and necessary step toward broadening access to treatment; however to make a true impact on the opioid epidemic, we must break the stigma surrounding MAT.

When it comes to recovery, the potential for relapse is high, especially in the early stages when resolve is fragile. It is important to note that for individuals with co-occurring mental health conditions, chronic pain or other addictions, MAT should be supplemented by treatment for those conditions, such as cognitive behavioral therapy. Building in care management support to assist in navigating the treatment process may reduce the possibility of relapse and/or readmission to a substance abuse inpatient or residential rehabilitation program. It also helps provide individuals with the tools needed to live addiction-free.

By taking the time to dispel the myths about non-traditional addiction treatment like MAT, we create an environment that more fully supports a return to complete health—physical, mental and emotional. Fighting the stigmas around MAT is an important step toward enabling those suffering from OUD to recover from their addiction and live healthy, vibrant lives.

There’s nothing quite like a good comeback. It’s a testament to the determination of the human spirit, and a reminder of why second chances can be a great thing. The beauty of a comeback is that it happens in many forms. It could be an athlete getting back on the field after a major injury, or a determined older student going back to school to finally earn their degree. For Adam McCullough, it’s finding his way back into the driver’s seat.

For most of his life, Adam, 28, lived without a disability. He grew up in Holmen, WI, and played college football at Macalester College in St. Paul, MN. After graduating, he got a job at the Minnesota Department of Agriculture as a hydrologist, where he’d gather samples of water from lakes and rivers and test what was in them. But on December 26, 2016, Adam was driving home and crashed his car after hitting an icy patch on the road. The accident left him paralyzed from the chest down.

At first, Adam’s main focus was learning how to navigate life in a wheelchair. Simply getting around his parent’s home on his own was a challenge. He set his sights on building strength through physical and occupational therapy, and took part in trial studies for new treatments. Over time, he regained some movement in his hands. As he became more independent, he realized just how much he missed driving.

“Little things pop in your head,” says Adam. “If I want to go to the grocery store by myself, I just don’t have that option. It’s been limiting, you know? I think anyone can picture that.”

Having made so much progress in other areas of his life, he started wondering if there was a way he’d be able to drive again. After talking with his doctor and doing some research, Adam told his TMG IRIS Consultant, Julie, of his new goal. They started this journey by first getting Adam an accessibility assessment to see what he would need to do to drive again. They then got Adam a learner’s permit so that he could practice driving an accessible vehicle. Adam also needed to take a driver assessment to determine the exact equipment he would need in his vehicle so that he could safely and easily drive. Finally, he will have to pass the Division of Motor Vehicles (DMV) road test to get his license.

Through it all, Adam and Julie have worked closely together. They spent time looking into funding options to cover the driving assessment and equipment, and options to purchase a van. Even when the road got long, they knew that together Adam could reach his goal.

“Julie is there every step of the way,” says Adam. “We educated ourselves and researched everything together. Without Julie, I wouldn’t be talking to you [about driving] right now.”

Of course, Julie is quick to say that Adam has been the driving force behind making all of this happen. His grit and persistence to get back to driving and regain independence is amazing, and she says it’s been wonderful to watch him continue to make progress in many different areas of his life.

“Adam has a passion for self-direction,” says Julie. “He’s coming to me saying ‘This is what I need, this is what I want.’”

In January, Adam was finally able to drive for the first time in two years when he test drove accessible vans to figure out which equipment worked best for him. The driving consultant feels confident that, after a few more sessions, Adam will be able to pass the DMV’s road test and get his driver’s license. He says he was thrilled to be driving his dad around for a change.

As Adam gets closer to getting his license, he’s excited for all the possibilities that will open up. Driving his dogs out to the dog park; getting himself to work on his own; visiting far-away friends. However, more than anything else, he’s simply excited to be behind the wheel again.

“When I get the car, I’ll turn the radio volume up all the way and just drive around by myself for an hour,” says Adam. “My dog will have her head out the window. Me just driving around and torturing people with my singing voice!”

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!

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.