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One way to reduce the cost of specialty drugs: Find the right place to get them

Aug 18 2015

Costs for the exact same medication and dose can be, on average, twice as high when given in a hospital outpatient setting as they would be in a doctor’s office or in a home.


It’s no secret: many specialty medicines are incredibly expensive. Drug costs for people battling complex, chronic diseases such as rheumatoid arthritis, multiple sclerosis, immune deficiencies and Crohn’s disease can total more than $100,000 a year. However, many people – and their doctors – don’t know that WHERE the drugs are given can make a big difference in the cost.

Some specialty medicines can’t be simply taken by the patient. Instead, patients have to go to a doctor’s office or hospital outpatient center, have a nurse come to their home, or be taught to self-inject or self-infuseLittle girl portrait with her family the medication that can be delivered by a specialty pharmacy. Sometimes a treatment requires multiple infusions with each infusion lasting several hours.

Often, a patient’s doctor will direct a member to a treatment site without a clear understanding of how the choice of site might affect costs. However, those differences can be considerable: Our data shows that costs for the exact same medication and dose are, on average, twice as high when given in a hospital outpatient setting as they would be in a doctor’s office or in a home. What’s more, the patient doesn’t always need the level of care available in a hospital or outpatient center.

If the patient is paying a percentage of the cost, that can cost the patient more money. It also means higher costs for the patient’s employer or health plan, which can lead to higher premiums for everyone.

Using the power of big data, Aetna’s pharmacy and data science teams collaborated to build a tool to direct members to the most cost-effective treatment sites, before treatment even begins. Whenever staff members get a call to approve coverage of the specialty medicine at a high-cost location, they can use a tool developed at Aetna to find and recommend to the doctor a less expensive location convenient to the member. The member gets the same medications, but at a better price.

The specialty drug tool is one example of how Aetna uses the power of big data to keep members better informed about their options, healthier and out of hospitals.

Containing any part of the cost of specialty drugs is critical. U.S. spending for specialty drugs is projected to grow more than 20 percent each year through 2020, with specialty drug spending expected to reach $402 billion. Patients who need these specialty medicines should talk to their doctor about all of their options.  In general, administering the drugs at home — whether delivered by a specialty pharmacy for self-administration or by a home health agency for administration by a nurse – or in the doctor’s office are the least expensive options. Getting them at an outpatient center or in the hospital is almost certainly the most expensive.

“Specialty medicines are very expensive but also offer new hope to those struggling with these diseases,” said Ben Bulkley, Aetna Vice President of Pharmacy. “Finding ways to keep costs as low as possible is an important part of our strategy, so that people continue to have access to the medicines they need.”