Expect More From... Navigating Complex Benefit Trends!

Don’t let What to Watch in 2024 or Top 10 Healthcare Trends for 2024 get you down. Yes, most of these articles are pessimistic in viewpoint; but here at Foundational Pharmacy Strategies, we see opportunity in the year ahead!

Throughout the month of January, we will dissect many of the common 2024 themes into thought-provoking and action focused articles. Be prepared to confidently discuss and decide crucial coverage options impacting members and future drug cost. Here is a sneak peek of what’s to come!

Is obesity, diabetes, cardiovascular, kidney or substance abuse driving trend? It can be hard to tell these days with GLP-1, SGLT2, Twincretins soaring in popularity and cost for all the above and then some. The American Heart Association (AHA) has recently coined a new acronym to tackle this evolution, CKM – Cardiovascular-Kidney-Metabolic. AHA provided a new advisory bulletin to manage the growing field of drug options with their expanded indications. The goal is to empower Primary Care Providers to treat patients’ multiple conditions themselves and get reimbursed accordingly. The new staging system is aimed to identify patients earlier in their disease (and younger in age) by providing additional screening, testing and guidance for Stages 0-4. While we brace for the escalating demand of these drugs (and those to come within the pipeline), we must recognize that patients will have different health journeys. In addition to those receiving these drugs through the usual channels, many other patients (due to cost or drug shortages for example) are dealing with counterfeit or contaminated compounded products that they have sought ought themselves. Millions more will stop therapy due to side effects, cost or desired non-drug alternative treatment plans creating an emerging significant unique health need. Regardless of the “why” or even “how,” we must be prepared to support the entirety of the patient which will require a range of options. Be prepared to answer member questions and vendor selection options confidently by building a sustainable and supportive structure.

Mental health continues to be at the forefront of discussion but have the rapidly growing options and vendors left you feeling anxious? Prescribed psychedelics and neurostimulation are garnering much attention in the new year. Patient confusion on ketamine (commercially available esketamine known as Spravato) and MDMA (commonly known as “ecstasy” which is seeking FDA approval in 2024) will create some crucial coverage soul searching. Aside from drugs, neurostimulation devices are becoming more popular. These options range from trendy, as some are being coined the new “Fitbit,” to other options requiring medical procedures for implanted devices. Can members use wellness dollars, or will coverage be provided through the standard benefit offerings? Will Mental Health Parity rules impact our decision-making processes? Let’s face these controversial questions directly, rooted in science and met with compassion.

CRISPER therapies arrived in late 2023 for sickle cell disease with full steam ahead for other cell and gene therapies in 2024. Although we expect these innovative therapies to treat rare diseases, 2024 may be the awaited push into chronic conditions impacting millions of Americans. Engensis is a great example of what’s to come. Engensis has been studied for tissue regeneration in common diseases with diabetic peripheral neuropathy and diabetic foot ulcers completing Phase 3 trials; claudication and ALS in Phase 2 trials; and Charcot Marie tooth disease and coronary artery disease in Phase 1 trials. Don’t let these promising treatments feel overwhelming. Establish an appropriate use clause and payment structure now to provide members proper access and avoid “surprises” later. 

Despite being challenged in court, Medicare Drug Pricing has officially commenced with the new year. Refresh your memory with a prior post Expect More From... U.S. Government! Will these changes make a material difference to lower drug costs for all, or will the private sector make up the difference? Many are sounding the alarm bells that drug prices for new-to-market agents may be pushed even higher to compensate for potential government losses anticipated in the years to come. A great example is an emerging class for Alzheimer’s disease, amyloid-targeted therapies, with three potential options likely available soon. The current benefits of these drugs have arrived with tempered enthusiasm due to concerns over the duration of prolonging disease and safety. Despite unease, this has not stopped drug manufacturers from requesting thousands of dollars per month per patient. Even if a fraction of eligible patients receive therapy and pay the desired price tag, this means big dollars for Pharma.

The issues we are going to face this year are complex and a “one size fits all approach” is not going to work.  These issues impact people’s quality of life, and employers need to deal with them in a compassionate, but fiscally responsible manner.  As always, Foundational Pharmacy Strategies is her to support employers navigate these complex issues.  We are grateful to our readers and supporters.

Questions, thoughts? We’d love to hear from you! Contact Us!