As diversity of drug type and indication increases, so does complexity of claims processing – Webinar Segment

As drug spend increases, so does the use of genetic tests. How does this affect claims processing? Watch to learn more:



So, the next question that we often hear from our clients is great, don’t need to worry about this on the pharmacy benefit, medical benefit, so what we did is we actually took all those 1,400 clinical studies and looked at, alright, well what type of route of administration of those drugs, and what type of drugs are they? So, if you look at small molecule drugs and you making an assumption that most of those are probably going to be oral, since most oral products are small molecules, you can see that that represents around 50-53% of those clinical trials that we were looking at. Now, if you look at the rest of those, with antibodies, biologics, antisense oligonucleotides, et cetera, more likely to be under the medical benefit, and you add those up, that’s about 50%. So, it’s a pretty consistent with what we’ve seen year over year, with the split being in drugs coming to market around 50% medical versus pharmacy. The other piece, when we look at the specific conditions that they treat, not surprising, we can see that there is a similar continuing trend that we’re seeing now with 60% targeting some type of oncology diagnosis, followed by cardiovascular, immunology, and CNS disorders. So, definitely something to keep in mind, and the fact that this is a cross benefit issue, it’s not a medical benefit issue, it’s not a pharmacy benefit issue, it’s an overall cost management issue that we need to think about, how do we best utilize information that we obtain from genetic tests to ensure that the patients get the most clinical effective treatment and then utilize that information properly. The last piece of information I’m going to talk about here is the fact that a lot of times when we’ve done a separate analysis looking at prior authorizations, what we found a lot of times is, well, for these drugs, yes, that are on the market, there is a requirement for a genetic test, but nobody is really collecting results. And that could be an issue, because a lot of these, if you’re looking at 60% of these drugs are on Oncology, chances are the patient is going to fail therapy and move into another drug, which might require another genetic test. And as Gillian was talking with these multi-gene tests, is that you’re potentially getting multiple results. And so, you don’t want to start increasing costs by requiring patients to go seek another genetic test to get results to a prior auth. So, there is an importance here around the connection of those areas around prior auth to the actual claim processing and that’s going to take us into what Jared will be talking about in a minute, here.

So overall, as you can see, an increasingly large portion of drug spend is going to be across multiple clinical areas and there is going to be probably genetic tests tied to those as well. And that to effectively manage these going into the future, you really need to start thinking about this in a more holistic manner, from prior auth all the way to claims processing.