Oct 30, 2024
Dr. Mark Campbell, Chief Pharmacy Officer at RxBenefits, a prescription benefit optimizer that works with self-funded employers to help them get the best clinical and economic value from their pharmacy benefit manager relationships. As the healthcare landscape has become more complex with the rise of specialty and high-cost drugs, a significant portion of an employer's pharmacy costs can be impacted by a small population. A key challenge is managing the volatility introduced each year by changes in the health of employees and their families while also managing costs for the broader covered population.
Mark explains, "The landscape for prescription benefits has shifted a lot over the course of my career. In 1998, for example, 35% of the prescriptions were generic, and 65% were branded. There was no appreciable amount of specialties at that time. And the average cost for a plan was probably in the mid-thirties per member per month. But with the shift we've seen where generics have grown to roughly 88% of the prescriptions for most of our groups, now the remaining 12% of brand and specialty drugs make up about 85% of the cost."
"And you could narrow that even further to say that roughly 2% of the members make up about 65% to 70% of the cost of a plan. And now we're getting into conditions, diabetes, and the non-specialty realm, which is a very large influence on the overall cost for a plan. Also we are getting into specialty therapies for a variety of conditions, whether it's inflammatory conditions like rheumatoid arthritis, psoriasis, ulcerative colitis, or certain types of cancers where we have new therapies that we didn't have several years ago."
"Even in many orphan conditions, we've seen new products come to market. That can be a significant benefit for patients who have either had limited or no therapy options for them in the past. So, beginning to help employers understand how to address that 2% of their population in a way that will get an elegant response for the member, getting the right drug for the right patient, and getting it at the right cost is where a lot of our emphasis is."
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