Identifying and Knowing Your High-Cost Members: How to Manage Your Specialty Drug Spend



Libby Johnson, Sr. Vice President, Data Intelligence

Controlling specialty drug costs and trends takes constant and careful vigilance. Yet many plan sponsors lack the tools or expertise to monitor integrated member spend on the small population of high-cost patients who utilize these specialty drugs. To do so, plan sponsors have to pull data from multiple sources (such as pharmacy and medical data), generate reports, and use different tools to get what they need.

In my 15 years in the drug industry, I’ve seen many plan sponsors struggle to manage costs, challenged as they are to find a single source of information for identifying and remediating a problem. I’ve developed a passion for helping clients manage their costs and trend and visualize their data, and that’s why I’m grateful for PSG’s ArtemetrxTM Specialty Monitor.

 

Finding hidden costs

Artemetrx Specialty Monitor is a SaaS tool that combines medical and pharmacy benefit claims, allows drill-down into member-specific detail, and helps provide actionable solutions. Our clients now have the information needed to seek solutions at their fingertips.

For example, I worked with a health plan that tracked and managed utilization of specialty drugs such as Soliris on their highest-cost members. However, they were unaware of other high-cost members, including one with more than a $1M spend on a drug for the treatment of gout. Artemetrx Specialty Monitor easily identified this anomaly using the Top Member Spend report (see figure below).

With Artemetrx Specialty Monitor, users can drill into the full patient view with encounter data, diagnostic events, and prescription medications—providing answers to critical questions such as whether the patient visited the ER or was hospitalized, or if they received an appropriate diagnosis (see images below). An integrated view of member-specific information is easily accessible in minutes.

 

 

Insight is in the details

The first step to manage costs is knowing, in detail, information about your highest-cost members. Next is identifying possible solutions. The high-cost patient in the above example was receiving Krystexxa for gout treatment at an outpatient hospital. The average sale price (ASP) reimbursement of Krystexxa was 309%—compared to average rates we typically see of 221%.1 The health plan was using this information to determine if the contracted reimbursement was correct or if the drug could be administered at a different site of care. With this insight, our client can better manage the high-cost patient, ensuring an optimal clinical outcome and lowest cost.  

The patient being treated for gout highlights the fact that it’s essential to track and manage all your high-cost members—not just the more obvious ones, such as cancer patients or those with hemophilia. Otherwise, you might miss out on key opportunities to manage spend and provide better clinical outcomes for your members.

 

What’s next

Want to learn how Artemetrx Specialty Monitor is the essential tool you need to gain control over your specialty drug spend once and for all? Contact PSG for a demo today!

 

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  1. 2018 Artemetrx State of Specialty Spend and Trend Report


Libby Johnson currently leads the analytics, reporting, and data management team. She has over 15 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.