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Report: Payers Exert Cost Controls on High-Cost Biologics to Treat Autoimmune Diseases

Newer biologic agents struggle to compete against blockbuster drugs

In a survey conducted by Decision Resources Group, a health care research firm located in Burlington, Mass., managed care organizations (MCOs) anticipated that their costs of covering biologic treatments of autoimmune diseases will increase by double-digit rates each year during the next 2 years.

The cost trend for rheumatoid arthritis (RA), which MCOs expect to average 19%, was a major concern for more than two-thirds of the 40 surveyed MCO pharmacy directors and medical directors. As a result, payers have increased cost controls on biologics, which has affected prescribing by specialists.

Moreover, the survey, which included 103 rheumatologists, found that 80% of the specialists have encountered moderate-to-strong control by payers when prescribing biologic agents for RA and psoriatic arthritis (PsA), whereas 74% of specialists noted this level of control for ankylosing spondylitis (AS).

“Autoimmune diseases represent the most costly class of specialty drugs for the nation’s payers, and they have responded by enacting controls that encourage prescribers to adhere to treatment protocols and prescribe MCOs’ preferred agents,” said analyst Chris Lewis. “With blockbusters like Enbrel, Humira, and Remicade enjoying first-line status, other therapies face the continual challenge of getting prescribed.”

In other key findings, close to 60% of surveyed rheumatologists said that their patients treated for RA, PsA, or AS are prescribed a biologic agent — typically after an initial trial and the failure of conventional disease-modifying antirheumatic drugs (DMARDs).

Among all of the restrictions and strategies to control the use of high-cost biologics, MCOs overwhelmingly apply utilization management controls, most commonly prior authorization and step therapy, to steer prescribers to preferred agents.

In response to increased payer controls, more than half of the surveyed rheumatologists reported that they adhere more closely to preferred drug lists and plan to do so in the next 12 months.

“Considering prescribers intend to adhere more closely to preferred drug lists as a result of increased payer control on biologics, drug marketers need to find ways to obtain preferred brand coverage on MCO formularies or risk losing patient share to competitors that achieve favorable coverage,” Lewis said.

About half of MCOs reported that a specialty pharmacy is commonly used to acquire biologic drugs for members with RA — a trend that may accelerate with the launch of more self-administered therapies, thus increasing the ability of payers to control costs, the report says.

Only 23% of MCO directors reported that their MCO restricts the site of care of infused therapies; among the rest, 45% anticipated adding such restrictions in the next 2 years.

Source: Decision Resources Group; August 20, 2014.

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Decision supported by data from more than 4,000 patients