By Deb Burrows, BS, MA, EMTP
Kollet Koulianos, MBA, NHF senior director of payer relations, opened the session, CCSC Presents: Managing Hemophilia at the Lowest Total Cost of Care.
“The Comprehensive Care Sustainability Collaborative (CCSC) was founded in 2014 and included a prominent group of HTC directors, clinicians and administrators, along with payer/managed care medical and pharmacy directors,” said Koulianos. “The goal of CCSC is to augment the sustainability of HTCs.”
Koulianos indicated that one CCSC focus for 2021 is to help distinguish the value of a comprehensive care model and HTC demonstration models to highlight the unique approach to providing access to high quality and reimbursable care.
James Kenney, RPh, MBA, said that hemophilia represents a top-10 cost driver in medical spending. “We have a high cost per claim and there is substantial forecasted growth in the drug trend,” he said. “We have a projected 53 percent growth in agents [for the next year]. One driver of growth in this trend is the anticipated arrival of gene therapy.” He said that bleeding disorders are a key plan priority in the next three to five years.
“The goal of payer management interventions is aimed at improving quality of care and managing costs to get a good balance of the two,” Kenney said. Patient cost-share is anticipated to increase. “Hopefully the increases will be reasonable.”
“Copay accumulator adjusted programs (CAAP) do not go toward the member’s deductible and out-of-pocket maximum,” Kenney said. “When they run out, patients may not get their medication because of cost.” Other unintended consequences of copay accumulators include the progression of disease, emotional and psychological distress, and patients not being given notice that they need to meet deductibles.
Mark Reding, MD, said that hemophilia therapy has developed over a long period of time, however gene therapy has had many changes over a short period of time and will require centers to evolve.
“Gene therapy will probably not include a huge number of individuals at first,” Reding said. “Males 18 and older, with severe hemophilia and no history of inhibitors, will be eligible for gene therapy, but not every HTC will be able to do all components of gene therapy. We need to start thinking about the different capabilities of the centers. Some may only follow patients; some may provide dosing.”
He said that the EU is leading the way in a model for administration and follow-up. This “hub-and-spoke” model calls for national hubs to prescribe and manage, and other HTCs (the spokes) monitor and stay in close communication with them. “Centers affiliated with academic institutions may have to serve as the hubs supporting the smaller spoke centers conducting patient follow-up.” Challenges exist when administration and follow-up take place in different settings. “We need to figure out how to break down these barriers.”
Shannon Carpenter, MD, MS, said that numerous factors threaten HTC sustainability, as health care reimbursement gradually shifts from volume to value. “Traditional models do not reward for outcomes. This is misaligned with the quality care that HTCs deliver. Comprehensive care and episode payments present an alternative to traditional fee for service.”
She shared examples of savings models and noted that resource accountability programs have care management payment and elements of utilization that include payment for performance. “HTCs can draw corollaries to the ACO model of value-based reimbursement,” Carpenter said.
Sal Morana, RPh, PhD, completed the speaker portion of the program. “Prescription spending has outpaced that of other medical services and remains a key concern for employers,” Morana said. “There is a growing appetite for solutions.” As a side note, he told viewers that COVID-19 has had a distinct and unique effect on pharmacy spending, which is expected to continue, including stock piling and unlimited refills.
Carpenter concluded that it is not more work to utilize payment for performance, but more of a mindset on how to do the billing. ■
There are so many ways to get involved at this year’s NHF Bleeding Disorders Conference—and beyond.
First, follow and connect through #NHF2021 on social channels. (Don’t forget to post your BDC selfies using the #NHF2021 hashtag!)
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