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Radar On Market Access: Large Employers Are Concerned About Million-Dollar Treatments

Posted by Leslie Small on Aug 27, 2019

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For large, self-insured U.S. employers, their No. 1 concern related to pharmacy benefits is how to finance treatments that come with seven-figure price tags.

That's one finding of the National Business Group on Health (NBGH) 2020 Large Employers' Health Care Strategy and Plan Design Survey, AIS Health reported. Among the 147 employer respondents, 86% said they were either concerned or very concerned about "the impact of million-dollar treatments getting approved by the FDA."
 
"The pipeline is looming — there are an estimated 14 new therapies in excess of $1 million each that are on the docket for FDA approval in the coming months and years," Ellen Kelsay, NBGH's chief strategy officer, said at a press briefing in Washington, D.C.

Nearly a quarter of large employers polled said that as of 2019, they are delaying the inclusion of newly launched treatments from their formulary to enable their PBM or health plan to better determine the treatment’s efficacy and safety, the NBGH survey noted.

Kelsay also highlighted the fact that 46% of employer respondents in the 2020 survey indicated they would consider a role for government in helping to negotiate prices for high-cost therapies.

"I think that's a reflection of the frustration employers have" with how to finance high-cost treatments, NBGH President and CEO Brian Marcotte said at the briefing. "It's not a question of are these good therapies. It's a question of what can society afford — not just what can employers afford."

When it comes to specialty drug management, the most notable area of growth is in the use of prior authorization (PA) for medications billed under the medical benefit. The share of employers using PA for drugs under the medical benefit rose from 36% in 2019 to 59% in 2020.
 


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Topics: Specialty, Market Access, Provider, Payer