P{alybook strategy on chalkboard The framework for the playbook has been adapted by theNational Alliance of Healthcare Purchaser Coalitions and isavailable to member coalitions throughout the country. (ImageShutterstock)


Considering that the annual cost of specialty drugs to treatcertain chronic conditions can exceed $100,000, theMinnesota Health Action Group has developed action plans that allstakeholders within the drug delivery chain can take to driveefficiency and transparency in the marketplace.


The group's Specialty Drug Employer Playbook details whateach stakeholder can do to advance the “5 Rights” for employers andconsumers—right drug, right price, right place, right support andright data. The framework for the playbook, a cumulative effort bythe Action Group's “Guiding Coalition” of 40 members across thedelivery chain, has been adapted by the National Alliance ofHealthcare Purchaser Coalitions and is available to membercoalitions throughout the country.


Related: Data and analytics bend specialty drug costcurve


The playbook lists four high-level goals that employers shouldexpect for each stakeholder group—health plans, providerorganizations, pharmacy benefits managers, specialty pharmacies andmanufacturers. These high-level goals are followed by detailedaction plans to achieve the goals—and scoring criteria thatemployers can use to measure how well each stakeholder isperforming.


“Inaction is not an option,” says Carolyn Pare, president andCEO of the Minnesota Health Action Group. “For years, employers andconsumers have been paying for things we don't even know we'repaying for. This has to change.”


“With the Playbook, employers will now be better equipped togain more control over specialty drug use and spend on behalf oftheir employees, which will ultimately contribute tostabilizing a very broken system,” Pare says.


The four high-level goals for health plans:

  1. Require submission of actual National Drug Codes (NDCs) andHealthcare Common Procedure Coding System (HCPCs), units, quantityand day's supply by all providers in all settings.
  2.  Contract with providers to assure cost parity of allsites of care for the same drugs and services.
  3. Involve employers in key decisions that affect their overallcosts.
  4. Align total cost of care (TCOC) and accountable careorganization (ACO) provider contracts so practitioners selectand/or administer high-value drugs.

Provider organization goals:

  • Include actual NDCs and HCPCs, units, quantity and day's supplyby all providers in all settings. Use NDCs for prior authorization,utilization management, payment, collection of rebates, claim levelreporting, data analysis, provider contracts and patientoutcomes.
  •  Include cost parity across all sites of care for thesame drugs and services in all contracts.
  • Ensure practitioners better know drug prices (what employersand consumers are paying) at the point of care to support the useof high-value drugs.
  • Align TCOC and ACO provider contracts so practitioners selectand/or administer high-value drugs.

Pharmacy benefit manager goals:

  • Accept fiduciary responsibility (ERISAdefinition).
  • Ensure a level of financial transparency so purchasers knowexactly how their money is being spent.
  • Provide claim level reporting, including all data fields, foremployer ad hoc analysis.
  • Involve employers in key decisions affecting their overallcost.

Specialty pharmacy goals:

  • Ensure a level of financial transparency for purchasers.
  • Ensure that high-level, timely clinical expertise supportsprovider decisions to use high-value drugs that the goal ofachieving optimal outcomes.
  • Make operational processes and decisions on behalf of thepurchaser, independent of the specialty pharmacy parentorganization's financial interests.
  • Provide/improve patient education and support that includestimely instruction on drug administration and emotional/socialsupport to increase adherence and improve outcomes.

Manufacturer goals:

  • Create a model of financial transparency that will assistpurchasers in making value-based decisions.
  • Discontinue consumer coupon programs that encourage use oflow-value, high-cost drugs in place of therapeutically equivalentgenerics.
  • Ensure that price increases over time do not exceed theConsumer Price Index (CPI).
  • Develop and implement value-/performance-based pricing.

“Transparency means different things to different people,” Paresays. “And ultimately, we need to push beyond transparency tosolutions that ensure employers and individual purchasers haveaccess to the right drug, at the right price, at the right time, inthe right setting, and that they have access to the rightdata.”


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Katie Kuehner-Hebert

Katie Kuehner-Hebert is a freelance writer based in Running Springs, Calif. She has more than three decades of journalism experience, with particular expertise in employee benefits and other human resource topics.