Real Questions, Real Answers: Specialty and the Medical Benefit

Renee Rayburg, RPh
Libby Johnson
January 20, 2021

Join the discussion already in progress as we shift gears from last week’s installment on Utilization Management: How to achieve best practices in the managed care spaceto this week’s segment on specialty management and the medical benefit.


Part Four: Specialty and the Medical Benefit – Specialty management and medical reimbursement strategies

Q: We received multiple questions specifically around the medical side of specialty management and medical reimbursement strategies.


Renee, can you comment on how we can ensure that payment on the medical side is as well managed as it is on the pharmacy benefits side? Do you have any new best practices you’ve seen that you can share concerning medical reimbursement management?


Renee Rayburg:

First, a common thing that all of us have talked about is access to the data. Everything hinges on that. Integrated data shows costs and the plan paid amounts across the different channels to have that comparison. We look at it every day and can see the highest reimbursements. It gives us the power to identify outlier providers. It’s one thing to understand if you have a high reimbursement issue, but it’s another thing to determine: is it the channel? Is it the provider? And build strategies around that.

In the same sense, having access to the data can help identify an outlier provider, which allows you to get things fixed. Now you can monitor their adherence to the current contract, those types of things, the tool can help you to monitor as well, ensuring whatever processes you’re putting in place continue to be optimized. Several drugs today cross over in individual disease states. We talked about utilization management earlier too, but we also see differences when looking at the reimbursements across channels that identify some of that duplicate therapy that Libby discussed earlier in this series.


For earlier segments in this series, check out Utilization & Medical Pharmacy Integration | Biosimilars | Utilization Management


Q: What specific examples should health plans have on their radar?

Renee Rayburg:

One drug that we found the data to be very important is Ocrevus. This drug is administered every six-months as an IV infusion for multiple sclerosis (MS). It’s most often, or almost always billed through the medical benefit. There’s no insight from the pharmacy benefit when a patient starts it. That’s another area where, to Libby’s earlier point, we can watch for duplicate therapy.

Artemetrx features reporting, such as our new high-cost member report, that can identify a patient within a month of starting therapy. There was a health plan where a patient was on Tecfidera, one of the oral MS therapies through the specialty pharmacy, and then they began Ocrevus.

The specialty pharmacy did not know that. The specialty pharmacy called the patient to send their refill. The patient didn’t understand because they weren’t used to only using the therapy once every six months. The patient ended up getting two more fills of their Tecfidera. At $8,000 a month, that adds up. It is crucial to understand how the data is key to any of these types of reimbursement strategies. Libby, I think you had a couple of ideas as well.


Libby Johnson:

From a medical reimbursement perspective and medical drug management perspective, there are a couple of things I’d love to add here. We’ve sprinkled some of these topics throughout, but I want to underscore three things here.

Let’s start with site of care channel management, which continues to be an area where we see a focus on the medical side. It’s not an “easy button” exercise from a channel management perspective.

What do I mean by that?

It requires a lot of analysis and understanding. It goes beyond what drugs are appropriate and into understanding the full picture about those drugs. Whether it’s rebates on the pharmacy side or medical drug rebates, plans need the whole picture to know where they achieve the lowest net cost. Those analyses feed into the type of conversations that plans are having when establishing their policies and/or rolling things out within their plans.

A couple of other things from the medical side are fee schedule management and going hand in hand with that is provider engagement. While it’s essential to understand the reimbursement from an Average Sales Price (ASP) perspective or an administration cost perspective on the medical side, getting to that information is number one. I think we’ve hit on how important it is, but then really understanding what to do with it comes next.

Big data has been a buzzword for a while now, but we’re still unspooling the possibilities of what we can do with big data. For data nerds like me, big data is very cool.

Q: The possibilities are endless, and I agree, Libby, that’s a very cool thing. With that, we reached the end of the questions submitted by sophisticated health plan leaders from all around the country.

Libby Johnson:

We’ll leave you with these insights and sincerely invite discussions in the future about your data, how we can determine where the opportunities lie for your plan to improve both the return on your investments and improve access to these life-changing specialty medications.


To learn more, download your copy of our fourth annual State of Specialty Spend and Trend Report.


Renee Rayburg helps lead Artemetrx services in Clinical Consulting with more than 30+ years in pharmacy and medical benefit management to support our health plan sponsors, providers, and patients.  Her thought leadership and passion for specialty pharmacy continues to influence the market, including important changes to specialty vendor clinical management products for the betterment of clients.

Libby Johnson currently leads the analytics, reporting, and data management team. She has over 16 years’ experience providing cost and trend management strategies to clients through unique data intelligence and analytics. Her expertise includes developing strategic cost solutions, creating advanced and specialized data and financial analysis plans, analyzing forecast and trend developments, and evaluating pricing and cost strategies and tactics. One of Libby’s key strengths is assisting clients in designing and deploying strategies to improve overall trend management program performance.