For several years, Express Scripts has been offering what it calls Care Value programs for certain disease states with specialty-drug therapies, ranging from diabetes to multiple sclerosis (there are 10 such programs, including oncology). Now, it is adding a Rare Conditions Care Value (RCCV) program to this set, with “rare conditions” defined initially as seven: hemophilia, Huntington’s disease, Gaucher’s disease, acromegaly, alpha-1 deficiency, hereditary angioedema and idiopathic pulmonary fibrosis. The RCCV program also features a tie-in with a health-advisory firm, PinnacleCare, to provide second-opinion and follow-in advisory services. Express Scripts claims that 77% of patient engagements with PinnacleCare have resulted in a change in diagnosis, treatment or care (although it’s not clear whether this is all types of PinnacleCare patients, or just those with rare diseases).
An Express Scripts spokesperson says that PinnacleCare can be brought in initially for a second opinion upon diagnosis, or when treated patients reach a certain claim threshold for medication costs, “which could be an opportunity to review and adjust their therapy.”
The Express Scripts documentation around its Care Value programs, including RCCV, shifts between touting better care for patients, and lower payer costs for plans. The company has documented higher adherence rates and better outcomes, with pharmacy services delivered through Accredo, its specialty pharmacy; at the same time, “cost containment” is a goal. PinnacleCare has the same ambivalence; the company started out providing VIP concierge care to patients, and now additionally offers cost-management services to payers.
Among the seven rare diseases in RCCV, says the company, there are currently 46 approved drugs, rising to 76 by 2020. The knock-down, drag-out fight between Express Scripts and Gilead Sciences back when the latter’s hepatitis C treatments were introduced, followed by Express Scripts temporarily denying coverage of Gilead’s Sovaldi in preference to AbbVie’s Viekira Pak, is instructive. Industry experts approached by Pharmaceutical Commerce note that cost containment is not new to the rare disease space (at least where multiple therapeutic options exist); the key is how much emphasis is put on cost control, and how much on patient support.