MITIGATING HIGH-COST CLAIMS - National Alliance of Healthcare Purchaser ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
ACTION BRIEF
Employer Strategies that Drive Health, Equity and Value
MITIGATING HIGH-COST CLAIMS
A CLOSER LOOK AT HEMOPHILIA
Although hemophilia is a rare disorder
ACTION STEPS FOR affecting about 25,000 people in the
EMPLOYERS: US, it ranks among the highest-cost
healthcare conditions, averaging
1. Use value-based
$270,000 per claimant annually.1
insurance design to
ensure that health As with many rare diseases, hemophilia
plans support patients commonly requires lifelong treatment.
with hemophilia and Because of hemophilia’s low incidence,
their families. employers often have little to no
understanding of the disease and
2. Set expectations what makes treatment so costly. Most
that health plans and
employers hand off the development of
other providers cover
hemophilia cost containment strategies
new, evidence-based
to intermediaries, such as pharmacy
treatments.
benefit managers (PBMs), carriers,
3. Ensure Hemophilia TPAs or pharmacy consultants. While
Treatment Centers these vendors may develop appropriate
are in all networks. strategies that result in the lowest total
cost of care, conflicts can exist that
4. Accommodate increase employer costs unnecessarily. implementation to vendor partners who
employees with
bleeding disorders When it comes to assuring optimal may be conflicted. This will help them
by providing on- or patient outcomes at the lowest total cost gain insight into the key cost levers that
near-site support. of care, employers should first consider drive spend, as well as which traditional
having dialogue with hemophilia plan design strategies can create access
5. Educate and cover experts, before simply handing barriers that can have a signficiant
health plan members off the strategic development and impact on spend.
with hemophilia,
connecting them to the “When it comes to rare diseases, like hemophilia, copay accumulator
right health benefits
and care management adjustment programs, and step therapy/fail-first language can backfire
resources. when implemented as a one-size-fits-all strategy. For patients and
payers alike, the unintended consequences that can result from these
obstacles can be catastrophic.”
—Kollet Koulianos, Senior Director of Payer Relations,
National Hemophilia Foundation.
UNDERSTANDING
HEMOPHILIA
Hemophilia is a bleeding disorder,
usually inherited, in which the blood
does not clot properly. With effective
treatment, most hemophilia patients
can live full lives and enjoy most of the
activities other people do.
Hemophilia results from a mutation in
one gene that normally directs clotting
factor proteins. As a result of impaired
clotting, unchecked bleeding can occur
within joints, causing chronic joint
disease and pain; in the head, causing
seizures and paralysis; or in other dollars in government funding have rare diseases from seeking treatment.
vital organs. been used to improve medical care, Instead, a “compassionate managed
services, education, and the safety and care” approach includes a more flexible
There are two types of hemophilia:
surveillance of factor replacement plan design that makes treatment of rare
Hemophilia A, resulting from a lack
products. diseases affordable and effective.
or deficiency of clotting factor VIII,
and hemophilia B, resulting from a For example, consider what is happening
WHAT EMPLOYERS CAN
lack or deficiency of clotting factor IX. with copay accumulator adjustment
DO TO EFFECTIVELY
Hemophilia A (classic hemophilia) programs. These programs are designed
ADDRESS RARE
is four times more prevalent than DISEASES SUCH AS
hemophilia B and is often severe. HEMOPHILIA The Triple Aim Approach:
Use value-based insurance design Optimal Outcomes at the
RECENT TREATMENT Lowest Total Cost of Care
to ensure that health plans support
ADVANCEMENTS
patients with hemophilia and their A high-cost rare disorder like
Treatment for hemophilia is advancing. hemophilia requires a high-
families.
Recent developments include novel non- touch care approach. Hemophilia
Care for rare diseases such as Treatment Centers (HTCs) are
factor biologic agents and investigational
hemophilia can be very expensive. federally recognized centers of
gene therapies. In gene therapy, the excellence that subspecialize in
Traditional plan designs have limited
patient’s defective gene is replaced with rare hemotologic disorders using
flexibility in terms of deductibles, an integrated, multi-disciplinary
a normal gene to enable the production
copayments and co-insurance. This approach to care—the “gold
of the active enzyme and prevent the standard.” There are 141 HTCs in the
type of design can have negative
development and progression of the U.S. A directory is available here.
consequences on employee health by
disease. Advocacy groups are pushing Having a chronic disease such
allocating resources to low-value care
for further care advances that can be as a bleeding disorder often
and discouraging employees from
provided at a lower cost. These include entails spending much time and
seeking high-value care for essential but effort navigating the healthcare
biosimilars, some of which are just
expensive treatments. system. At an HTC, hematologists,
finishing clinical trials and high-cost gene pharmacists, nurses, social workers,
therapies that are coming for hemophilia. The consequence can be that employees psychosocial professionals,
(or their dependents) do not seek and physical therapists provide
The National Hemophilia Foundation
adequate care for rare diseases because coordinated treatment at one
(NHF) has advocated for the needs location with services available
of unaffordable out-of-pocket costs,
and interests of people affected by 24/7/365. Contracting with HTCs
resulting in both a lower quality of life
hemophilia and related bleeding as in-network providers enables
and ultimately more-costly care as the employers to improve patient
disorders for almost 60 years. NHF outcomes and manage treatment
disease, unchecked, results in more
advocates educate elected officials and costs. When HTCs are not in
serious consequences.
others in healthcare and government the plan network and specialty
about the unique needs of people with In other words, traditional plan designs pharmacy is carved out to an
exclusive provider, total cost of care
bleeding disorders. As a result of can be less effective, with built-in cost
can increase significantly.
efforts at the federal level, millions of barriers that discourage employees with
to help employees with rare diseases safer and more effective than traditional
reduce their out-of-pocket expenditures treatments.
when they need expensive drug Payers are encouraged to make sure
treatments. However, the application their benefit plans cover these new
of these copay accumulator programs treatments. For treating hemophilia,
is being challenged in recent CMS doctors now have access to recombinant
rulings. As a result, employees end up factor VIII, artificially created in a lab.
paying more for the drugs they vitally Recombinant factor VIII can be used
need. Employers can design plans to instead of factor VIII obtained from
lower copays for effective, high-cost rare human blood (frozen plasma), avoiding
disease care. the risk of viral infections, which are
The University of Michigan Center sometimes transmitted in human blood.
for Value-Based Insurance Design is The NHF is supporting the advancement
promoting Value-based insurance design of gene therapy, as scientists better What is Value-Based Plan
(V-BID) principles for marketplace and qualify who might be best suited for the Design?
employer health plans. These designs therapy. Issues of cost and long-term “It’s the idea that insurance design
seek to eliminate the underutilization durability, efficacy, and safety are being should be built on the concept
that high-quality treatments and
of high-value care, such as that for determined. providers should cost less. This
hemophilia, that occurs when plans
Ensure your health plan offerings kind of smart pricing is intended
allocate more resources to low-value to improve health and minimize
include providers with hemophilia
care with no clinical benefit. With value- waste.”
experience and expertise.
based plans, employers incur savings by —Tara Bishop, MD, MPH
HTCs represent the gold-standard
making high-value care more accessible
model of care for the management of
and affordable to employees.
bleeding disorders. These specialized Accommodate employees with
Set expectations that health plans
centers provide comprehensive care for bleeding disorders by providing on-
and other providers cover new,
individuals with hemophilia, including or near-site support.
evidence-based treatments.
the development of specific treatment Under the Americans with Disabilities
New treatments for hemophilia are plans, monitoring and follow up of Act, employers are obligated to
becoming available. Often, they are affected individuals, and state-of-the-art accommodate employees with bleeding
medical care. disorders. In particular, if asked by the
This care results in documented employee, employers must:
improvements in outcomes, including Provide the employee with a private
a lower likelihood of death, fewer place to self-administer infusions.
hospitalizations, and lower use of
Offer a safe place for the employee to
emergency services.
store needles and infusion supplies.
Individuals who go to HTCs will not
Educate and cover health plan
only receive outstanding medical care,
members with hemophilia,
but also benefit from an experienced,
connecting them to the right health
caring staff that takes time to develop
benefits and care management
comprehensive treatment care plans for
resources.
patients and families. Since hemophilia
is heritable, genetic counseling is Tutorials on rare diseases and best
included to help families make informed treatment practices are available from
reproductive and other decisions. national organizations and can be shared
with employees with these conditions.
The treatment centers not only provide
For example, the NHF promotes a five-
specialty care but also act as a resource
step regimen for people with hemophilia:
for primary care doctors and dentists.
This approach can serve as a benchmark 1. Get an annual comprehensive checkup
for other network provider options. at a hemophilia treatment center.
2. Get vaccinated—hepatitis A and B are important for those with severe REFERENCE
preventable. disease because infusion of factor VIII 1 Zhou ZY, Koerper MA, Johnson KA, et al.
3. Treat bleeds early and adequately. concentrate is most effective within one J Med Econ. 2015:18(6) 457-65..
hour of the onset of a bleeding episode.
4. Exercise and maintain a healthy
In general, rapid treatment is important
weight to protect your joints.
because it reduces pain and damage
5. Get tested regularly for blood-borne RESOURCES FOR
to the joints, muscle, or other affected
infections. EMPLOYERS:
tissues or organs; improves quality of
Additionally, care management life; and boosts productivity. • National Hemophilia
resources can be used to train Foundation
Employers can take action to ensure
individuals with hemophilia who may • Midwest Business Group on
that employees with rare diseases get
need to self-administer treatment, such Health Hemophilia and Bleeding
their jobs done while also managing
as prophylactic (i.e., preventive) factor Disorders Toolkit
their health at optimal levels. By
infusions or on-demand factor infusions, • Comprehensive Care
understanding and honoring the
depending on disease severity. Sustainability Collaborative
rights of rare-disease patients and
Parents and affected individuals can be making resources available to help • Centers for Disease Control and
trained to administer infusions at home. them perform their duties, employers Prevention, Hemophilia
Self-infusion training is a service that create a supportive environment where • Mayo Clinic: Hemophilia Best
is provided as part of HTC-delivered employees with hemophilia and other Practices
comprehensive care. This is especially rare conditions can thrive.
ACKNOWLEDGEMENTS
With gratitude, the National Alliance acknowledges support from the National
Hemophilia Foundation by way of clinical expertise and funding to produce this
Action Brief. Final content was determined by the National Alliance.
1015 18th Street, NW, Suite 730 · Washington, DC 20036
(202) 775-9300 (phone) · nationalalliancehealth.org
twitter.com/ntlalliancehlth
https://www.linkedin.com/company/national-alliance/
The National Alliance of Healthcare Purchaser Coalitions (National Alliance) is the only nonprofit, purchaser-led organization with a national and
regional structure dedicated to driving health and healthcare value across the country. Its members represent private and public sector, nonprofit, and
Taft-Hartley organizations, and more than 45 million Americans spending over $300 billion annually on healthcare. Visit nationalalliancehealth.org, APRIL 2021
and connect with us on Twitter.
You can also read
