Payer Update – It’s All About the Data!
By Jeff Blake

Why do payers need and want data? And why do I need to agree to an assay management provision in my contract with payers? These are all great questions.

So why is data so important? Payers are concerned about the cost of hemophilia treatment and the pipeline of hemophilia treatment therapies. Payers want to manage and better control the cost of hemophilia treatment and care. This is a great opportunity for HTCs to explain and highlight the value of the HTC integrated comprehensive clinical and pharmacy services model. So how do HTCs do this?

It’s all about the data. HTCs need to have the ability to gather and track key data elements and be prepared to report this data to payers. So, what data are payers interested in seeing? Payers are very interested in assay management; the number of doses patients have on hand when they reorder and the ability to home/self infuse. Why are payers interested in this data?

Solid assay management is key in managing the cost of hemophilia. In general, clotting factor prescriptions are written at specific dose +/- 10%. For some patients, the additional 10% of a prescription can be over 50,000 – 100,000 units of clotting factor that would be dispensed. This can increase the cost to a payer by over $100,000. Rumor has it that our competitors, specialty pharmacies and home care companies, tell payers HTCs are very good at clinic care but not very good at assay management. I agree with their clinical care statement but strongly disagree with their assay management statement.

Payers also want to know their members, our patients, are not hoarding clotting factor. You can track this information when a patient reorders their next doses and by not dispensing “bleed” doses when a prophy patient has not reported any “bleeds” since their last order. Payers also often don’t understand dosage and dispense variation among patients. For example, some assume that every patient is the same; a 300 pound man playing community basketball should have the same dosage and product usage as an 8 year old boy that isn't as active. We often have to explain that many variables can explain product usage and explaining certain patient characteristics is part of the telling the story of how we manage patients and subsequently manage product usage.

Payers are very interested in the lowest cost of treatment. Home/self-infusion is by far the lowest cost of treatment. For example, the cost of clotting factor is 2 – 4 times more costly in the hospital than treating at home. Do you track the patients that can treat at home/self-infuse? Do you document the training provided so patients can treat at home?

So, the key takeaways are – track, manage and report assay management, patient doses at home when ordering and home/self-infusion data to payers. More importantly, let the payers you work with know how well you care and manage your patients!!

If you have any questions or would like our assistance in your payer relations efforts, please contact a member of the Hemophilia Alliance Team. We Work For You!