Should Patients be Paid to Move Their Tx?

Curiouser and curiouser…….
The pharmacy management rabbit hole seems to be getting curiouser by the day. The article below details a very new and provocative tactic to pull patients off one therapy and onto another, one that has clear benefits for the PBM and questionable clinical benefits for the patient.

Like all PBMs lately, changes to drug formularies have seen drugs moved to non-preferred status or even to ‘no longer covered’ in favor of another that is now preferred. What is unique is that Express Scripts is offering a cash bonus to certain patients on specialty therapy to drop their established therapy in favor of the new, preferred drug. Sure, $500 is enough to catch a patient’s attention and perhaps grease the skids to force a change. But the article points out that there may be unexpected clinical consequences with making the switch.

Also, the program isn’t offered across therapies or even across therapeutic categories. The article below notes that the current program only targets psoriasis patients. That raises the question….. Who benefits most? We all know that rebates are behind every preferred formulary decision so the answer can be easily construed that the PBM could be the bigger winner.

This may be a trial balloon, but it is noteworthy. Will we see similar deals offered to prompt more patients to move their specialty therapy? Will PBMs that use this technique also get blow back from other members who are not offered similar incentives?

“It takes all the running you can do just to keep in the same place.”
— Lewis Carroll

Express Scripts Dangles $500 to Persuade Patients to Switch Psoriasis Drugs

March 26, 2021 — As the first quarter of 2021 ends, patients choosing to keep using secukinumab may be offered an inducement by their pharmacy benefit manager to switch to another biologic, ixekizumab.

Is a $500 debit card from a pharmacy benefit manager (PBM) the new carrot in patient incentives in annual formulary changes?

Every year, PBMs change what’s covered and what’s not, often in specialty drug categories but also in older classes of drugs.

This year, one of the more notable switches was the removal of secukinumab from the formulary for Express Scripts, owned by Cigna. Patients are being given the option of switching to another inhibitor of interleukin (IL)-17A, ixekizumab.

Both drugs are used for psoriasis and psoriatic arthritis. Secukinumab (Cosentyx) is sold by Novartis and ixekizumab (Taltz) is sold by Eli Lilly. In some plans, secukinumab was removed entirely; in others, it was moved to a higher-priced tier.

Now, nearly 3 months into 2021, patients who choose to keep using the therapy may see communications about the offer, according to one dermatologist who shared the letter with The American Journal of Managed Care® (AJMC®).

The letter, sent this month to clinicians, advises them of patients who are still using secukinumab and offers alternatives, including older biologics, in addition to ixekizumab. Patients would receive the debit card if they fill the first prescription before August 31 and the second before December 31, with the card to follow 6 to 8 weeks after that.

The practice, known as non-medical switching, “is a very hot topic right now,” said Mark G. Lebwohl, MD, a professor of dermatology at the Icahn School of Medicine at Mount Sinai, where he is also dean of clinical therapeutics.

“A standard thing in medicine is, if you are doing very well on a treatment, why would you stop it?” said Lebwohl, who is also on the medical advisory board of the National Psoriasis Foundation (NPF).

In a statement to AJMC®, Cigna, which owns ExpressScripts, said patients were “offered several alternative medications that are equally effective and more affordable.”

“In rare occasions when a patient is not able to use the preferred option, we recommend that our clients offer an efficient review process to assist those patients in obtaining a non-formulary medication in these instances.”

Lebwohl disagreed, saying, “They say there is an appeals process, but everything they do is onerous.”

With the rise of specialty drugs, usually biologics, non-medical switching has become more of an issue. Specialty drugs make up a little more than 2% of US prescriptions, but account for half of drug spending, and that share is expected to rise.

Dermatology and rheumatology are 2 of the specialties most often affected.

“They pick on dermatology for sure, because they figure no one’s going to die,” said Lebwohl.

Indeed, a paper led by the Institute for Clinical and Economic Review (ICER) and published in the Journal of Comparative Research, referenced that idea, noting that, “Many economic-step therapy policies involve dermatologic, antihypertensive and gastrointestinal motility drugs that treat conditions for which short-term failure with the first-step drug poses extremely little risk of any significant long-term harm.”

The paper proposes a set of what is calls “ethical goals for access and fair design criteria” that could be used to spur “transparent and accountable drug coverage,” including points that should be satisfied if required switching is to take place.

However, the authors also note that their ideas will likely leave everyone unhappy.

“It will leave some patient advocates and clinician representatives feeling that too much weight has been given to the importance of managing limited health care dollars, and that too much discretion has been allowed to payers to construct policies that put patients at risk,” the authors conclude. “Conversely, many payers will feel that this paper questions unfairly their moral compass; that their commitment to evidence is discounted, while their efforts to make sure that patients are not hurt by inappropriate prescribing lie undefended from misplaced suspicions that the bottom line drives their actions.”

The NPF is having conversations with payers and PBMs about these issues, said Leah McCormick Howard, chief operating officer of the NPF. Part of that conversation is education about the systemic nature of psoriasis, she said.

“From an NPF perspective we’re always concerned about policies that require or would encourage an individual in our community who’s stable on a therapy to switch to another therapy,” she said.

Neither she nor a pharmacy professor had ever heard of an incentive set that high.

“A lot of time patients get really attached to that drug because it is working for them and it can take them 1 to 2 years to adjust to a new product,” said Nicole Henry, PharmD, assistant professor at The College of Pharmacy at The University of Arizona.

Both Henry and Howard noted that the list of exclusions by PBMs have been growing in recent years.

Lebwohl suggested that the issue has more to do with the rebate system that exists between drug companies and PBMs. Both biologics are priced similarly.

Allison Inserro


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