Therapy optimization: a new model for managing high-cost biologics.

Evidence-based and population-based disease management programs have progressed from concept to creation of an industry in just short of a generation of healthcare. Today, most health plans provide DM services either themselves or through contracts with dedicated DM service companies, like Matria Healthcare and Healthways (formerly American Healthways). Large employers also have gotten involved through their health plans or by contracting directly with DM vendors. But even with the recent trend toward consolidation — a sign of a mature industry — DM companies primarily serve the common chronic diseases: diabetes, chronic heart failure, asthma, and chronic obstructive lung disease. With rare exceptions, the DM industry — as well as MCOs — have ignored the less-common chronic diseases, especially those such as multiple sclerosis, which are treated with expensive biologic therapies. And although some DM companies offer some basic case-management services for these diseases, true population-based DM programs are few and far between. Specialty pharmacies are in a unique position to offer comprehensive outcome improvement programs for rare diseases, says author Thomas Morrow, MD. These therapy optimization programs also present a growth opportunity for SPs with little increase in operations cost. PHOTOGRAPH BY STAN KAADY Therapy optimization initiatives for rare diseases have no natural focal point in a typical MCO — they don’t have the needed manpower or the patient relationships needed to produce improved outcomes cost-effectively. MCOs also have been reluctant to contract for the management of these diseases because of their limited populations within any single health plan. Instead, most MCOs use a specialty pharmacy to manage the high-cost specialty drugs used to treat these diseases. Mainly, SPs provide services like prior authorization, drug and supplies acquisition, and compliance-and-persistency oversight, but not the kind of in-depth DM services that health plans offer with common chronic diseases. Therapy optimization programs present an opportunity for SPs to expand their services and provide added value in patient care. Once an optimization program is initiated for one disease process, it is relatively easy to use the template to create programs for other high-cost diseases.