Health experts discuss improving access to specialty meds through V-BID approach

NEW YORK — Complex specialty medications often represent the most appropriate clinical recommendation for patients battling such serious health conditions as cancer, rheumatoid arthritis and multiple sclerosis but they can be complicated to deliver and carry very high costs. However, some health experts argue that there are tactics that payers and purchasers can deploy to help improve patient access.



One such tactic — Value-Based Insurance Design — is getting a lot of attention and was the topic of a Webinar that the National Pharmaceutical Council hosted on Monday.



The Webinar, moderated by Kimberly Westrich, director of Health Services Research at NPC, included presentations by:

• A. Mark Fendrick, director of the University of Michigan Center for V-BID;

• Will Shrank, chief scientific officer and chief medical officer, provider innovation and analytics, CVS Health; and

• Brian Klepper, CEO of the National Business Coalition on Health.



Specialty pharmaceuticals can be extremely effective in treating serious health issues, but the reality is that such drugs come at a cost — a high cost. In fact, the NCP noted that $600 or more per month is a common threshold. Or, for a specific example, consider the Hepatitis C treatment Sovaldi, which has a list price of approximately $1,000 per pill and $84,000 for a 12-week course.



Today, roughly one-quarter of total pharmaceutical spending in the commercial market is dedicated to specialty drugs, and, if the current trend holds, it may comprise half of all pharmaceutical expenditures by 2018.



In an effort to reign in spending, many payers have established requirements for high consumer cost sharing for specialty medications. However, such requirements often lead to non-adherence for many patients and that means poor health outcomes. That’s where V-BID comes in.



While V-BID programs are not exactly a new concept, some health experts are recommending that V-BID principles be applied to specialty medications. Currently, most V-BID programs focus on removing financial barriers for drugs to treat chronic conditions like diabetes and asthma.



V-BID is a tactic that payers and purchasers can use to promote access to high-value specialty medications, according to some health experts. It is a model of insurance design that provides more generous coverage for services that offer known, evidence-based value and less generous coverage for those where value is low, as explained by the NCP. In other words, V-BID is pivoting your thinking from “how much” to “how well” health dollars are being spent. It is driven by the concept of clinical nuance, which recognizes that medical services differ in the benefit they provide, and that the clinical benefit derived from a specific service depends on the patient using it and when/where the service is provided.



“I think we should have a robust dialogue on what the role of incorporating clinical nuance in a benefit design might be as we look more carefully and rigorously at the evidence around specialty pharmaceuticals,” Fendrick told attendees.



Added Fendrick, “We would very much like to see a reduction, or in some cases, an elimination of financial barriers to high-value clinical services and those high performing providers.”



Echoing the sentiment, Shrank said, “This is a less of a revolution and more of a modest evolution, I think, from a standard Value-Based Insurance Design to now this notion of a specialty Value-Based Insurance Design.”



Shrank went on to discuss a recent analysis done by the CVS Health Research Institute that outlined some of the challenges regarding Sovaldi, the highly effective — yet highly expensive — treatment for Hepatitis C introduced in December.



“Here we are finding ourselves in this really, really unique and sort of challenging scenario where it is not about the quality or value of the drug but is more about the population effects of the very expensive drug,” said Shrank. “It is here that we find these Value-Based Insurance Design questions to really resonate.”



Representing the purchaser perspective in Monday’s discussion, Klepper called for “equal scrutiny.”



“What I’m getting at is that the approaches that we take need to be financially nuanced, as well as clinically nuanced, and there are lot of questions here. For example, why do we need to take the current pricing structure of any particular drug for granted?” Klepper said. “… The deeper questions might be things like: What is the actual development cost? What is pricing in other countries for the same thing? And what care cost does this particular drug displace? What are the contributions to total profitability? If this is, in fact, such a wonderful thing then are the manufacturers willing to go at risk for their performance? … These are important questions and they need to be asked.”