Program designed to ensure members receive hemophilia drugs from organizations meeting the highest quality standards, and to reduce drug waste/fraud
PITTSBURGH, Pa. (Nov. 19, 2019) — Highmark announced a new partnership focused on the treatment and management of hemophilia, which aims to ensure that members receive hemophilia drugs from organizations that meet rigorous performance standards and to reduce drug waste and fraud that increases costs. Beginning in January of 2020, Highmark members will receive hemophilia drugs exclusively from three providers: Option Care Health, Soleo Health and the Hemophilia Center of Western Pennsylvania.
Hemophilia is a rare genetic disorder that causes patients to have difficulty forming blood clots because they lack normal levels of proteins called clotting factors. Without sufficient clotting factors, patients can experience prolonged and life-threatening bleeding after an accident, spontaneous bleeding into the joints and large muscle groups, and long-term damage to internal organs and tissues. Most people with hemophilia are diagnosed as infants or as small children, and begin a lifelong regimen to control the bleeding disorder that includes self-administered or guardian-administered IV infusions of drug products containing their type of missing clotting factor.
Highmark health plans have approximately 190 members who have been diagnosed with hemophilia. Highmark spends around $80 million annually on care for hemophiliacs, with about 90 percent of that total attributed to pharmacy costs.
Highmark selected the participants for its hemophilia partnership through a competitive RFP process.
"The organizations in our high-performance hemophilia partnership are true centers of excellence in the treatment of this complex, chronic condition," says Ned Finn, Highmark’s director of specialty pharmacy services. "By partnering with these organizations, we are able to obtain hemophilia drugs for our members at a competitive rate while establishing new performance guarantees and oversight protocols for providers. Our members will work with organizations that possess exceptional knowledge of hemophilia, and will receive the right drugs and dosage at the right time. The end result is a higher level of care for our members, as well as potential cost savings for members and group customers."
This partnership also aims to address fraud, waste and abuse (FWA) related to high-cost hemophilia drugs.
"Highmark understands that the risk of FWA associated with prescription drugs, including those used to treat hemophilia, are high," says Kurt Spear, VP of Financial Investigations and Provider Review (FIPR) for Highmark. "Over the past year, Highmark has identified and stopped multiple FWA cases involving complex schemes aimed at driving excessive and inappropriate reimbursement for hemophilia drugs. Our new network is another step to mitigate these risks for our customers."
The new program complements Highmark’s Hemophilia Member Care Program. Through the program, Highmark identifies members with hemophilia based on risk and links them to a multidisciplinary care team that includes a nurse, pharmacist, physician, other clinicians and behavioral health providers. Members receive an individualized care plan and education that helps them better understand and manage their condition.
"Managing hemophilia can be a complicated process," Finn says. "Our goal is end-to-end treatment for our members that removes barriers to better health and allows them to enjoy the highest quality of life possible."
ABOUT HIGHMARK INC.
One of America's leading health insurance organizations and an independent licensee of the Blue Cross Blue Shield Association, Highmark Inc. (the Health Plan) and its affiliated health plans (collectively, the Health Plans) work passionately to deliver high-quality, accessible, understandable, and affordable experiences, outcomes, and solutions to customers. As the fourth-largest overall Blue Cross Blue Shield-affiliated organization, Highmark Inc. and its Blue-branded affiliates proudly cover the insurance needs of 4.5 million members in Pennsylvania, Delaware, and West Virginia. Its diversified businesses serve group customer and individual needs across the United States through dental insurance, vision care and other related businesses. For more information, visit www.highmark.com.
Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.
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