Genomic, curative drugs for chronic and terminal diseases are
perhaps the most exciting new treatments in medicine. But even though these
highly tailored therapies come to market with the potential to save costs for
the health care system, the industry is struggling to pay for them because of
their high up front costs.
Neil Lund, chief actuary and vice president emeritus of CVS
Health Corp., observes that PBMs are already perceived as honest brokers by the
plans they contract with. He says PBMs are a possible conduit to share the
information necessary for the evaluations of health care products and services
with all stakeholders.
"At the core [of a PBM] is this claims processing
engine," Lund says. "[They have] a lot of real-time electronic data
and the ability with really excellent record keeping as the fundamentals
involved."
While the rebate-driven model for purchasing traditional
pharmacy products works well for maintenance and incidental treatments,
purchasing curative specialty pharmacy products is more complicated. For
payers, such therapies have the benefit of reducing the need for chronic care
and lessening risk of an inpatient stay, but they also have to front a high
capital cost that disproportionately benefits providers and manufacturers, Lund
observes.
Yet different metrics can yield different understandings of a
new therapy's value, said Brian Leinwand, an associate principal for health
economics at Avalere Health, during a recent webinar on alternative financing
models for emergent therapies.
"[Decision-makers] typically evaluate products' incremental
cost per quality-adjusted life-year gained compared to another therapy or
therapies. However, a quality-adjusted life-year is not always the most useful
metric for decision-makers in these scenarios, [and] other techniques can be
employed."
Lund says member churn adds complication to curative therapy
pricing. If a member receives an expensive curative therapy with one plan but
departs for a new one a few years later, the new plan benefits but doesn't
share in the cost.
"In the short term, the base case issue here is whoever is
covering the person at the time of the very expensive treatment, in the way we
handle everything today, is on the hook for the full cost," Lund observes.
"Subsequent insurers or organizations reap the benefit of that, not the
organization that necessarily footed the bill."
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