Abstract

Hemophilia patients consume large quantities of biologicals. Many are on prophylactic regimens which cost substantially more and have better outcomes as compared to on-demand treatment. In either situation, 95% of costs of care are biologics. As costs are high, third-party payers frequently challenge various treatment regimens. Aetna Inc., working with nurses and a hemophilia treater, initiated a systematic evaluation program of 400 members with hemophilia enrolled in HMO plans to investigate whether these costs could be appropriately controlled. Several caveats were agreed to:

  1. No therapeutic modality would be changed unless medically indicated.

  2. Patients would be supported to have an annual visit to a comprehensive center, if they were not already followed by one.

  3. Changes where biologics were purchased were only done with physician and client agreement.

Over the past three years, substantial savings have been accomplished PMPM (per member / per month fully-insured HMO member).

The annual spending PMPM for biologics

PMPMTotal dollars
Before program 2003 $0.66 25,650,021 
Year 1 2004 $0.60 23,832,539 
Year 2 2005 $0.54 21,309,444 
Year 3 2006 $0.54 19,395,661 
PMPMTotal dollars
Before program 2003 $0.66 25,650,021 
Year 1 2004 $0.60 23,832,539 
Year 2 2005 $0.54 21,309,444 
Year 3 2006 $0.54 19,395,661 

The savings were attributable, in the main, to simply shifting how and where biologics were purchased and could not have been accomplished without the federal PHS pricing program. In three years’ time, annual savings per patient were substantial. The savings per subscriber encouraged Aetna, Inc. to continue this program.

Author notes

Disclosure: No relevant conflicts of interest to declare.