McKesson's Holbrook divides outcomes into three buckets—financial, clinical and utilization—and says that payers want to know
monetary savings on drugs, wastage, generic substitution rates, unit cost savings and the impact on total costs. Both Holbrook
and Russek are concerned about cost offset—will the cost of drug therapy for hepatitis C, for example, outweigh the cost of
a liver transplant? Clinical outcomes encompass patient and physician satisfaction and measure functionality for those with rheumatoid arthritis,
viral elimination for hepatitis C patients and fewer relapses for MS patients. Utilization focuses on the use of one drug
over another and how many services patients have received. (See http://www.managedhealthcareexecutive.com/holbrook for Holbrook's article, "MCOs face financial challenges with growing specialty pharmacy segment".) Like his peers, Phillips at PharmaCare believes that reporting outcomes is not always a smooth road, especially, he says,
because the drugs are so expensive with many different outcomes to consider. "It is a mixed bag," he says. "Payers may not be asking for measures on a regular basis, but they also are not willing to
pay for data collection." The cost of tracking outcomes is an expensive proposition for specialty pharmacy—a barrier posed
by more than one company. WHO WANTS WHAT Phillips questions who holds responsibility for measuring and collecting data and where information should reside—with educated
patients who are probably aware of their lab values, the plan or in an electronic medical record. "There is room for channel conflicts in reporting information," he says. His primary focus is on whether a drug is achieving clinical therapeutic benefit. Similar to Holbrook, Phillips creates three
outcome buckets: appropriate use, side-effect management and clinical outcomes. PharmaCare sponsors ProtoCall programs, which combine treatment guidelines, provider coordination, patient support and reporting,
including cost management, compliance initiatives and forecasting capabilities. Its efforts in measuring compliance with medications
for specific disease states showed that there was a 10.6% increase in compliance for participants with MS and a 2.4% increase
in compliance for those with rheumatoid arthritis in the ProtoCall program compared with those who opted out, leading to higher
remission rates. Emily Cox, senior director of research for Express Scripts, a large PBM headquartered in St. Louis, questions what payers
are requesting and how they plan to use the information. She also is challenged by data that are often patient self-reported
measures, putting the onus on specialty pharmacy to contact patients in a timely manner. Express Scripts conducted research that studied the relationship between copayments and compliance and expects to determine
the effect those results will have on final outcomes, such as emergency room visits and hospitalizations. Cox says that she
found that higher copayments have less effect on compliance with specialty drugs than with traditional medications, a finding
that she anticipated for the more expensive drugs that rarely have generic alternatives. All and all, Vogenberg says that specialty pharmacy is searching for ways to be responsive to clients, focusing on the distribution
and pricing side, and are now being challenged to provide more metrics that translate into a value proposition. Mari Edlin is a frequent contributor to Managed Healthcare Executive. She is based in Sonoma, Calif.
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