Cost of Care

Geisinger clinical effectiveness program credited with stabilizing biologics costs

May 8, 2019 2:24 pm

April 17—Biologics comprised less than 1% of Geisinger Health’s claims but were approaching 50% of its total drug spending. That is, until a comparative effectiveness program halted the rapid increase.

The advent of highly effective but costly biologic drugs had created massive cost pressures for Geisinger Health Plan, said John Bulger, DO, chief medical officer.

In 2014, biological drugs comprised 24.2% of Geisinger Health Plan’s total drug spending. By 2018, the share was 35.9%, even as such drugs represented only 0.77% of the health plan’s drug claims, Bulger said this week at a briefing of congressional staff.

But the health plan credited broad implementation of a systematic approach to population management with nearly arresting that increase, with biologics representing 36.1% of total drug spending so far in 2019.

“We thought we were going to up to about 50% [of drug spending] being biologics, and we actually bent that curve,” Bulger said in an interview. “We are seeing definite savings for the last year.” 

The approach, which aims in part to cut the 17-year average time it takes to incorporate medical research into practice, follows several steps:

  • Research current literature and guidelines
  • Develop a best-practice consensus
  • Establish procedures for process evaluation and updates
  • Empower patients
  • Implement robust reporting
  • Align health plan, provider and patient incentives

Addressing obstacles to implementation

Some of the biggest savings from the program have been in psoriasis care. The health plan examined its enrollees’ results from different treatments and found that use of a light box for phototherapy was much more effective than costly system biologics.

The process also found ways to overcome obstacles to implementing that finding, such as feedback from patients that they preferred to take the drugs due to their relative ease of use. To overcome that reluctance, the health plan developed and disseminated educational materials for patients that outlined the evidence for the plan’s preferred approach.

Another barrier was a lack of alignment with payment policies, which resulted in lower costs for patients if they used the costly medication option. The health plan addressed that issue by extending full coverage to the light boxes.

The key to success

The most important factor in the program’s success, said Bulger, was the team-based approach.

“A lot of times you rely on a single clinician at a single practice,” Bulger said. “Even if that clinician has things like electronic health records and other things behind them, it’s difficult to keep up with everything that’s going on.”

Teams that include pharmacists and nurses can back up physicians and ensure they have the most up-to-date research on treatment for specific patients. For instance, a key to improving hepatitis C treatment efficacy was the finding that some patients require four additional weeks of treatment beyond the standard eight weeks.

“It maybe didn’t matter when the choices [came down to] a dollar, but it matters more when the choices are thousands of dollars for the drug or when you have drugs that have a lot of side effects,” Bulger said. 

The approach has been expanded from Geisinger providers to other providers paid by the health plan, and applied to a growing number of diseases.

When Geisinger Health Plan started the effort, the hepatitis cure rates from curative biologics were 50% because the enrollees could go to any provider. So, the health plan changed its benefit design to drive enrollees to Geisinger providers, where cure rates approached 100%.

“The biggest outcome is do you cure the disease?” Bulger said.

Geisinger has achieved about a 99% cure rate with its comparative effectiveness process, which compares to national cure rates that range from 85% to 90%.

“A lot of this is physicians, and they don’t have time to do stuff, so you create a team to do things. You have a pharmacist to be able to educate patients and you have the shared decision making,” Bulger said. “Then, it doesn’t have to be the physician in a 20-minute visit having that shared decision-making discussion. You have conversations with social workers and other things.”

The team approach allowed Geisinger to address social determinants of health (SDOH) that influence medication adherence, like the inability of some to refill prescriptions because they couldn’t afford to travel to the pharmacy.

“A lot of the outcomes were from that as well,” Bulger said, referring to SDOH factors.


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