Part 2: Brian Gifford on How Treatment Adherence Can Help Employers Save

To watch part 1 of this interview, click here.

The Center for Biosimilars® (CfB): Hello, I'm Matthew Gavidia. Today on MJH Life Sciences' Medical World News, The Center for Biosimilars® is pleased to welcome Brian Gifford, research director of the Integrated Benefits Institute [IBI].

You've stated that through misdiagnosis, employees may never get a shot at [antirheumatic] drugs and their conditions may lead them to long-term disability. What solutions might there be for this?

Gifford: Well, never is a long time, but I think that delays in diagnosis potentially could end up putting people at a higher risk of going into the long-term disability system. Now, I would caveat all of that by saying I don't work in the area of clinical outcomes so, I'm not really sure what the solution for that would be in terms of how we get people better diagnoses. But I would advise that the goal is always to manage the condition better so that people can have their lives back, pain free, and free of mobility limitations.

But if one of the business goals is to keep people out of the long-term disability system, this is where we start to ask employers to think about how their formulary plan design complements return-to-work-from-disability leave policies. So, are you thinking about how you are going to communicate the availability of certain kinds of therapies to occupational nurses, for example, that you may hire or retain, to help employees stay on the job or get back to work from a disability leave?

It's really about integrating a larger strategy and not just taking things piecemeal based on cost. Although, of course, costs, or expense, if I want to be consistent with my terms, is always going to be expensive. Expenses are always going to be important to how employers think about their policies, but I would advise that, for the goals of keeping people on the job and keeping people performing at a high level, we're really looking for ways that they can have different benefits policies complement one another.

CfB: And not only misdiagnosis, but as you just alluded to, health plan designs such as excessive co-pay requirements may be causing nonadherence. Can you discuss this?

Gifford: I can, but let me let me pull that apart a little bit. I would push back a little bit on the term "excessive co-payments" as, of course, causality is always really difficult to establish, but here's what we know about the relationship between co-pays and medication adherence. An IBI study found that if you were to raise a co-pay for rheumatoid therapies by $20, you [would] cut adherence by about a third. And so, does that mean that the co-pay is excessive?

Well, it seems to work against the goal of making sure that people with rheumatoid arthritis are really well managed. It may also cut against the goal of keeping people on the job. So, finding exactly the right co-pay amount, and it's not just co-pays but things such as deductible amounts that can help employers save money, by passing those costs on to the plan enrollees.

But they have to understand that they may be sacrificing other kinds of things. If it leads to this longer-term chain of causality, and people are not adherent to their medication, it's impacting their health, it requires them to take more time off of work either incidentally with sick days or with short-term disability and, hopefully not, but long-term disability leaves, which may be the first step toward leaving the labor force. Those are also costs, and employers cannot shift those costs to anyone else. They're always going to absorb the costs of ill health insofar as it impacts productivity.

CfB: Let's say perhaps co-pay requirements are the wrong way to control costs for rheumatoid arthritis. What's your opinion on this?

Gifford: Well, again, I wouldn't say it's the wrong way to control costs, you can always control costs by passing them on to someone else, in this case, the patient. I would encourage employers to really think about the goals of what they're trying to do.

A CFO [chief financial officer] who participated in one of our panels years ago advised me that employers don't adopt benefits policies just to manage the expenses. They are trying to do something with those policies. They have some larger business goals or benefits goals, and I would just encourage employers to think of that as well. How would changing a co-pay, or how would increasing a deductible or, conversely, how would lowering a co-pay or lowering a deductible have an impact on people's ability to manage any chronic conditions they have and stay on the job and be productive?

CfB: Are biosimilars, such as infliximab, making much of a dent in these rheumatoid arthritis costs for employers and payers?

Gifford: IBI hasn't really studied the issue of biosimilars compared to biologics. And again, I think that the value proposition is going to be there. Clearly, if a therapy is less expensive than an alternative and it gets widely adopted, and is just as effective, then you're going to see a drop in expenses. That's by design and that's by intent. Nobody's going to expect anything differently.

But, again, if we're talking about the longer-term costs, I think those demonstrations still need to be done. We still need to have more research showing that people who are taking biosimilars are not only as healthy and as functional as anyone else, but that their function is actually playing out and providing some value to employers because people are better able to stay on the job and they're able to work with less pain. They are able to contribute more and provide value in that way.

CfB: Besides co-pay requirements, other payer policies have an effect on employee access to effective care for rheumatoid arthritis. Can you discuss these?

Gifford: There are all kinds of ways that employers and people who were helping them manage their formulary, for example, their pharmacy benefit managers, are really trying to ensure that people are getting the therapies that they need [rather than ones that don’t match their conditions].

So, prior authorizations for some kinds of drugs showing that it's medically necessary. That's an important step. That's certainly something that is between the provider and the patient. But you have to understand that if you have a prior authorization, it could take a little bit longer for people to receive their prescriptions. For example, step edits, requiring that people try and fail to respond to preferred drugs, and quantity limits are decisions that are going to be made between patients and their doctors. And I'm certainly not going to advise that we would change that process, but we at least have to understand that like co-pays and high deductibles, prior authorization, step edits, and limits on quantities do represent a barrier to getting people effective treatments, particularly new treatments.

CfB: If you had a checklist of things employers could do to reduce the cost of rheumatoid arthritis in the workforce, what would be on that list?

Gifford: I'm going to stick with a broader term of costs, as opposed to simply medical and pharmacy expense. So, again, the cost reduction goal here is going to be this larger opportunity cost from loss productivity due to illness. This is really going to come back to ensuring that all of your different benefits are designed so that they complement one another so that, for example, your formulary is supporting people's ability to stay at work and return to work. And understanding how these 2 parts work together and, quite frankly, a lot of employers don't.

So, really, it's aligning this larger benefit strategy as opposed to saying that they're going to manage the pharmacy benefit in one silo, the health care benefit in another silo, the disability benefit in a third silo, and as many silos as we have for the different things that we're trying to accomplish

So, again, this is this is where the [IBI] actually got its original guiding principle. In fact, the name of the firm suggests that these strategies need to be integrated. And that's not just a data integration issue. That's a strategic integration and it's also trying to keep in mind that ultimately, all of these different things are going to be integrated at the patient level. What looks like silos to an employer are actually part and parcel with the way people go through their everyday lives.

CfB: Among employers that have taken these steps, what kind of results are you seeing?

Gifford: I wish I could answer that question. I wish I could say that I knew of employers that are really taking this kind of exhaustive strategic approach to the issue of biosimilars, formulary plan design, chronic diseases such as rheumatoid arthritis, and disability and sick day absences. Just insofar as we're talking about rheumatoid arthritis and biosimilars, I'm not aware of employers who are really taking this view.

I think that employers have a good opportunity because the chronic conditions that they have focused on in the past such as back pain and mental health issues, are actually going to become the model for how we should deal with other chronic conditions, particularly those that are going to be treated with specialty pharmaceuticals.

So, when I say how have employers been doing in this case, I think that case study of somebody who's managing it really well is still out there. I know that they focus on expenses. But how they are looking at their formulary plan insofar as it affects these other outcomes, I think that key employer who is doing this well is still out there but as of yet I'm not aware of who that is.

CfB: And lastly, do you have any concluding thoughts?

Gifford: I'm going to go back to IBI's guiding principles. IBI was founded 25 years ago as a way to get people to think outside of their benefits silos and start thinking about the health of the person insofar as that is a contributor to business success. So, my parting thoughts are going to be kind of my opening thoughts as well, which is, think about how all of your benefits fit together. Think about not just your health care benefits, but your disability benefits your paid leave benefits and think about how these can be designed in ways that complement one another, rather than being changed in a piecemeal fashion.

CfB: To learn more, visit our website at centerforbiosimilars.com. I'm Matthew Gavidia. Thanks for joining us.