Specialty Drug Benefit
Management:
Raymond Rupert MD. MBA.
Rupert Case Management Inc.
Specialty Drugs Are Smart:
• Rituximab (Rituxin) by Roche can improve
survivorship in lymphoma by 50%
• Smart drugs create fewer side effects
Specialty Drugs Are Costly:
• Average cost $65,000 per person per year
• Doctors using two or three biologicals at
one time
• Problem: managing the rapidly
escalating costs of specialty drugs
The Future Looks Expensive:
• 641 class D drugs licensed in Canada
• + 800 specialty drugs in the pipeline
• 35,000 patents in 2009 for specialty drugs
RCM’s Integrated Service:
• RCM manages the total
specialty drug benefit from
start to resolution
• for TPAs,
• benefits consultants
• insurers
• drug plans or employers
RCM’s “Lean On Me” Service:
• This service provides the client with a:
– Mentor
– Advisor
– Medications Expert
– Purchasing agent
– Logistics manager
– Confidante and
– Friend
OUR NEIGHBOURHOOD:
Infusion centers
Distributors
Suppliers
Cold chain
Competitive
sourcing
Monitoring/Aftercare
Genetic marker testing
Public funding
Coordination of
care
Private funding
Purchase
siRNA
Finalize Rx
Employer funding
Coordination of
benefits
PAP
Clinical trials
Prior authorization
Other sources
RCM
Customer
Clinical Plan
review
Determine Tx
options
Alternatives
Rx
Treatment
review
Case conference
Treating doctors
Top DOCS
Evidence based report
Clinical researchers
Gord’s Case Study:
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Gord is a 60 year old business person
Leukemia + Non-hodgkins lymphoma
Rituxin from Roche was advised
Not eligible for the provincial plan
Coverage with his private drug plan
Infusion issue in hospital
Outcome: 50% improvement
in survival
RCM’s Enhanced Customer
Experience:
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Clarity in communications
Decision support that is impactful
Guidance that is relevant
Effective advocacy
Emotional support
Engagement of patient
+ family
RCM Provides Decision Support
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Audit the clinical situation
Review the treatment plan
Source second opinions if required
Invites outside experts to a virtual case
conference
• Keeps patient fully informed
Pharmacogenomic Testing:
• RCM arranges tests for genetic variation
• Determine if drug will work and ensure that
side effects will be minimized
• HER2 test with Trastuzumab (Herceptin)
• K-RAS test with Cituximab (Erbitux)
• EGFR test with Gefitinib (Iressa)
Option of Clinical Trials:
• RCM tracks clinical trials
• Understands the entry criteria
• Assesses the design
• Blinded
• Unblinded
• Placebo group
• Completes the paper work
• Ready with Plan B, C, D if rejected
RCM’s Job One: Ensure
Appropriate Utilization:
• RCM ensures that:
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The right person
Gets the right medication
For the right indication
At the right dose
At the right time
Through right route
At the right price
For right length of time
Many Possible Funding Sources:
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RCM can seek public or private funding
RCM uses patient assistance programs
Access pharma company sponsorship
Access employer funding on an exception
basis
Co-ordination of Benefits:
• Careful juggling of benefits practiced here!
RCM Monitors Compliance +
Adherence:
• RCM monitors if the drug is being used
properly to achieve the best possible
outcome for the cost incurred
RCM Delivers Lowest Cost
Sourcing:
• RCM seeks the lowest cost product using
competitive sourcing
• RCM understands “off label” indications
• Different products with same benefit sold
at markedly different price points
Realize Cost Savings:
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Treatment of macular degeneration
Use Lucentis $2000 per treatment
Or use Avastin at $100 per treatment
Savings for the drug plan of $1900 per
treatment with RCM’s benefit management
RCM’s Client Monitoring:
RCM provides monitoring and aftercare for
as long as is needed
Benefits Of Retaining RCM:
• 1. Lower costs for the employer + the plan
• Improve the sustainability of the plan
• Delivery of performance metrics
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2. Seamless transitions
3. Continuity of care
4. Enhanced customer experience
5. Hopefully better outcomes
6. Enhanced employee loyalty
To Learn More About RCM’s
Specialty Drug Benefit Management:
• Call- 800 620 7551