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Payers Exert Cost Controls on High-Cost Biologics to Treat Autoimmune Conditions

Newer Biologic Agents Struggle to Compete in a Class Dominated by Blockbusters, According to Findings from Decision Resources Group

BURLINGTON, Mass., Aug. 20, 2014 /PRNewswire/ -- Decision Resources Group finds that surveyed managed care organizations (MCOs) anticipate that their costs of covering biologic treatments of autoimmune diseases will increase by double-digit rates each year the next two years. The cost trend for rheumatoid arthritis (RA), which MCOs expect to average 19 percent, is a major concern for more than two-thirds of the 40 surveyed MCO pharmacy directors/medical directors. As a result, payers have increased cost controls on biologics, which has affected prescribing by specialists. The survey, which also included 103 rheumatologists, indicates that 80 percent of the specialists encounter moderate-to-strong control by payers when prescribing biologic agents for RA and psoriatic arthritis (PsA), while 74 percent of specialists note this level of control for ankylosing spondylitis (AS).

Decision Resources Group Logo.

Other key findings from the U.S. Physician & Payer Forum report High-Cost Biologics for Autoimmune Diseases: How Will Healthcare Reform and Payer-Led Cost-Taming Strategies Impact Brand Prescribing?:

  • Prescribing of biologic agents: Close to 60 percent of surveyed rheumatologists said their patients treated for RA, PsA and AS are prescribed a biologic agent—typically after an initial trial and failure of conventional disease modifying antirheumatic drugs.
  • Utilization management controls: Among all the restrictions and strategies to control the use of high-cost biologics, MCOs overwhelmingly apply utilization management controls, most commonly prior authorization and step therapy, to steer to preferred agents.
  • Adherence to preferred drug lists: In response to increased payer controls, more than half of surveyed rheumatologists reported they adhere more closely to preferred drug lists and plan to do so in the next 12 months.
  • Specialty pharmacy use: About half of MCOs reported a specialty pharmacy is commonly used to acquire biologic drugs for members with RA—a trend that may accelerate with the launch of more self-administered therapies, thus increasing the ability of payers to control costs.
  • Site of care restrictions: Only 23 percent of MCO directors reported their MCO restricts the site of care of infused therapies; among the rest, 45 percent anticipate adding such restrictions in the next two years.

Comments from Decision Resources Group Analyst Chris Lewis:

  • "Autoimmune diseases represent the most costly class of specialty drugs for the nation's payers, and they have responded by enacting controls that encourage prescribers to adhere to treatment protocols and prescribe MCOs' preferred agents. With blockbusters like Enbrel, Humira and Remicade enjoying first-line status, other therapies face the continual challenge of getting prescribed."
  • "Considering prescribers intend to adhere more closely to preferred drug lists as a result of increased payer control on biologics, drug marketers need to find ways to obtain preferred brand coverage on MCO formularies or risk losing patient share to competitors that achieve favorable coverage."

Upcoming webinar:

About Decision Resources Group
Decision Resources Group offers best-in-class, high-value information and insights on critical issues within the healthcare industry. Clients rely on this analysis and data to make informed decisions. Find out more at www.DecisionResourcesGroup.com.

All company, brand, or product names contained in this document may be trademarks or registered trademarks of their respective holders.

For more information, contact:

Decision Resources Group
Christopher Comfort
781-993-2597 
[email protected]

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SOURCE Decision Resources Group

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