Health Affairs, 25, no. 5 (2006): 1318 doi: 10.1377/hlthaff.25.5.1318 © 2006 by Project HOPE	New Online   Senate Health Reform Bill   Rewarding Providers   Public Option Policy Brief   Health Reform & Abortion   Delivery System Reform

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Specialty Drugs

PROLOGUE

Specialty Drug Management

Whole bodies of medical, public health, and policy discourse, including Health Affairs’ recent public health thematic issue, have asserted and substantiated the efficacy of population-level approaches to preventing and managing chronic disease. However, resurgent increases in U.S. health spending, spiking again in recent years in the wake of the retreat of managed care, have triggered the evolution of new cost containment strategies, including consumer-driven health care and health savings accounts, that place increasing emphasis on the role of individual decision making—seemingly stymieing collective disease-control efforts.

One of the principal health care cost drivers, of course, has always been pharmaceuticals. Traditional cost-control devices, including the imposition of mandatory generics and prior authorization protocols, have met with some success in arresting the growth in outpatient drug spending. Specialty drug costs, however, distinguished by their greater reliance on biotechnology-originating substances and serving only about 1–5 percent of typical health plan enrollees, have stubbornly resisted containment and are, indeed, projected to spike sharply, particularly in the wake of newly introduced drugs.

The papers that follow chronicle health plans’ wranglings with specialty drug costs, often necessary for management of chronic conditions, and the implications for consumers in this post–managed care, individual-centered era. First, Dana Goldman and colleagues offer data from more than fifty health plans describing the variability in coverage of specialty drugs for cancer, kidney disease, rheumatoid arthritis, and multiple sclerosis and the resulting out-of-pocket spending among patients. Next, Daniel Mullins and colleagues offer insights into management strategies for outpatient specialty pharmaceuticals derived from a survey of thirty Blue Cross and Blue Shield plans. Perspectives follow from Douglas Monroe and colleagues and from John Watkins and colleagues, relating experiences with managing the use of biotech-derived products of Kaiser Permanente and the Washington State "Blue" plan, Prevera.

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