The breakthrough hepatitits C drug Sovaldi has brought the high price of specialty pharma to recent public attention. But less examined are proactive approaches insurers and drug benefits managers could use to curb the growth trend without depriving patients of needed therapies.
Through 2018, there will be a 17 percent compound annual growth rate in U.S. specialty drug spending and it could account for more than half of all drug costs, according to Alan Lotvin, MD, EVP of speciality pharmacy at CVS Caremark. Lotvin spoke Thursday at AHIP Institute 2014.
For instance, Copaxone, Teva Pharmaceuticals’ injection-based multiple sclerosis drug, debuted in 1996 at a price of about $1,000 per month, Lotvin said. By 2008, it was priced at $2,000 per month and nowadays is hovering around $5,000. That type of pricing growth is forcing a range of public and private payers to start making hard decisions, possibly tradeoffs, especially when it comes to Sovaldi, sold by Gilead Sciences at about $80,000 per course.
Medicaid programs, most of them mandated with covering drugs, are warning about troubles ahead — many billions that would need to be spent to treat patients, at the risk of crowding out other state services at the exhorbitant per treatment price. In Oregon, though, where a federal waiver offers the Medicaid program more flexibility, state health leaders are planning to limit Sovaldi access only to the sickest of the estimated 20,000 Oregon Medicaid beneficiaries carrying the virus.
Limiting access?
Sovaldi is quite unique among drugs, including speciality drugs, in that it “cures disease,” said Lotvin, a former interventional cardiologist who entered the pharmacy benefits industry in the late 1990s. “We don’t cure a lot of things.” But it also offers an opportunity to develop new ways to manage drug benefits, he said.
For hepatitis C, which can stay nascent without creating harm for years, a patient's liver can be monitored regularly via ultrasound and when signs of damage start to appear, treatment can begin. This buys time until Sovaldi’s price comes down or similarly-successful competitors become available.
Other conditions that need specialty drugs could be approached with strategies that don’t limit access when the evidence of benefit is clear but do emphasize the most affordable options, Lotvin explained.
“On management, we need to monitor the literature much more closely,” he said. “We can be much more aggressive without sacrificing quality.”
For patients with HIV, he said, “you can get almost exactly the same antiretroviral activity” with multiple generic pills daily as with the once-daily branded drug.
In Crohn’s disease, Lotvin said, home care has shown promise for reducing emergency room visits. For Crohn’s patients who start taking the artificial antibody infliximab (sold as Remicade by Johnson & Johnson's Janssen) and intravenous total parenteral nutrition treatment, infection is a real risk. Rather than patients having the ER as the default for treating infection, regulator home visits can help either prevent infection by IV checkups or by catching infection early on and starting antibiotic treatment.