By Angela Maas
Republished with Permission from AIS Health
Specialty drug trend in 2021 largely recovered from the hit it took from the COVID-19 pandemic in 2020, driven mainly by an increase in utilization. That’s according to the 2022 Artemetrx State of Specialty Spend and Trend Report from Pharmaceutical Strategies Group (PSG), an EPIC company.
Published in August, the report is sponsored by specialty pharmacy Reliance Rx. Findings are based on an Artemetrx analysis of 73.9 million medical claims and 55.1 million pharmacy claims from PSG’s book of business. It is the sixth annual version of the report.
From 2019 to 2020, specialty trend slowed to 11.8%, down from 12.8% the prior year, but from 2020 to 2021, it rose to 14.2%. That’s one of the top findings from the report, according to a PSG/Artemetrx team. “The percentage of members taking at least one specialty drug increased notably in 2021 (5.5%, up from 4.8% for the previous two years). Even a slight increase in the percentage of members taking specialty drugs can have substantial cost implications on a PMPY [i.e., per-member per-year] basis,” they tell AIS Health, a division of MMIT.
According to the team, the report’s “most notable finding was that trend returned to pre-pandemic rates. While this was not necessarily a surprise, it was difficult for anyone to predict when trend would return.”
Of the overall specialty trend, 9.4% of it was due to an increase in claim utilization, with the remaining 4.4% attributed to cost-per-claim changes. “This data suggests that more people are using specialty drugs, which are getting increasingly expensive,” observes the team. “When we started the report six years ago, cost per claim was the primary driver of trend. Whereas this year claims utilization is the primary driver of trend, which reflects the evolving and changing specialty drug landscape over the past six years.”
The PMPY drug cost in 2021 was $1,295, up from $615 in 2016, a time when trend was driven mostly by cost per claim.
The rise in utilization, says the report, is due to new users of specialty drugs as opposed to an increase in use among people already taking them. In 2021, 5.5% of the population used at least one specialty drug, up from 4.9% in both 2019 and 2020.
“We believe this is driven by the entrance to the market of specialty drugs to treat more common disease states and existing specialty drugs seeking and securing expanded indications,” says the team. “Previously, we had seen that a small number of members, around 1%, were using specialty drugs and responsible for a large percentage of overall drug costs. At that time, many specialty drugs were used to treat rare conditions. While this remains true, we have seen the entrance of specialty drugs to treat more common conditions such as asthma and atopic dermatitis over the last couple of years.”
Pharmacy Benefit Had Bulk of Specialty Spend
The report reveals that 64.5% of specialty spend was in the pharmacy benefit last year, a percentage that continues to grow. PBMs can drive use of the pharmacy benefit through strategies “such as rebates and other financial incentives that can make the pharmacy channel more cost effective,” observes the PSG/Artemetrx team.
In addition, “manufacturers have developed self-administered dosage forms for asthma drugs like Xolair and Nucala, as well as Ultomiris, an IV-infused drug for treating a couple of rare conditions. Some payers are considering strategies to shift members to these self-administered dosage forms, the billing for which will occur through the pharmacy benefit, which often can be easier and more transparent when tracking drug costs.”
Among categories of specialty spend, the top three — inflammatory disorder, oncology and multiple sclerosis — remained the same as the previous year. Immunological disorders rose to the No. 4 spot, swapping places with blood cell disorders. The skin – immunosuppressant category continued to rise, coming in as the eighth category, up from ninth last year and 14th the year before. The growth is mainly driven by Dupixent (dupilumab), which was approved in 2017 as the first biologic for atopic dermatitis and has since gotten approval for almost 10 more indications.
The class recently gained a handful of new agents: Adbry (tralokinumab-ldrm), Rinvoq (upadacitinib), Cibinqo (abrocitinib) and Opzelura (ruxolitinib). The team tells AIS Health that they anticipate the new drugs driving additional utilization. “In addition to differences in dosage forms, there are differences in pricing across the products. Payers need to have insights into plan-paid costs when assessing formulary placement and coverage of these new drugs.”
Among the top 10 drugs, six were for inflammatory disorders, led by Humira (adalimumab). That drug will be facing no less than seven biosimilars next year, though, and the report recommends that as those competitors launch, “plans should consider disease states when formulating their strategies.”
The team explains that many agents within the inflammatory class are available to treat a variety of conditions, including rheumatoid arthritis, psoriasis and Crohn’s disease. “As plans consider their biosimilar strategies, diagnosis can help refine that strategy even further. For instance, in the case of hidradenitis suppurative (HS), Humira is the only approved biologic for the treatment. Whereas for other diagnoses, therapeutic alternatives may exist. Also, diagnosis can indicate the specialty physician treating the diseases. Plans may consider certain strategies by specialty for encouraging the adoption of lower-cost alternatives, such as biosimilars.”
Payers, they recommend, “need to understand what condition(s) Humira is being used for and how their members are benefiting from drug therapy with Humira. However, since it is billed through the pharmacy benefit, the diagnosis is not required with the prescription when being filled at the pharmacy but rather collected during the prior authorization process, as most payers have utilization management for Humira in place.
“Access to integrated data, available through our Artemetrx tool, offers these insights as we collect medical claims, and the tool looks across the medical claims to link the diagnosis for Humira use,” they continue. “Interestingly, the less common uses for Humira, such as HS, an inflammatory skin condition, are the bigger drivers of trend. HS is not a very common condition, affecting approximately 1% to 4% of people in the U.S., and Humira is currently the only biologic FDA approved for this condition.”
Biosimilars Continue to Gain Market Share
Biosimilar use rose from 12.4% in 2020 to 22.5% in 2021. Biosimilars of Neupogen (filgrastim) — Zarxio (filgrastim-sndz) and Nivestym (filgrastim-aafi) — had the most market share, at 76.1%, up from 74.0% in 2020 and 70.2% in 2019. Semglee and Semglee Pen, biosimilars of insulin glargines Lantus and Lantus Solostar, had the least market share, at 0.1%, but the biosimilars launched toward the end of 2021, on Nov. 16.
The next-lowest market share was for biosimilars of Remicade (infliximab), at 22.6%, up from 16.9% in 2020 and 10.0% in 2019. However, the report shows that since January 2018, the average sales price per unit for both the reference drug and its biosimilars has continued to decline.
“The data shows that the uptake of biosimilars continues to increase across our book of business year over year,” says the team. “But more importantly, our data show that the presence of biosimilars continues to drive down the cost of all drugs in the market basket, including the brand reference product shown with Remicade and its biosimilars highlighted in the report.”
Asked about what some of the report’s main takeaways for payers are, the PSG/Artemetrx team replied, “Access to data is key to managing specialty drug spend optimally. Through data, payers can understand the specifics of what is driving trend to then develop strategies that directly address those areas. Traditionally the primary focus has been on the unit cost of specialty drugs. While that needs to continue, as we all know that specialty drugs are high cost, our report shows that utilization is the biggest trend driver. To achieve optimal results, you must manage both cost and utilization.”
Betsy Van Alstyne