D-SNP Saves $11M in Part B Drug Spend with Improved Utilization
About the Client
- Plan Type: Dual Special Needs Plan (D-SNP)
- Plan Size: 50,000 members
- Geography: New England
Issue
A small Dual Special Needs Plan (D-SNP) in the northeast faced unsustainable pharmacy costs. In particular, its Part B drug spend far exceeded that of peer benchmarks. Monoclonal antibodies (mAbs), used to treat cancer and autoimmune conditions, accounted for more than 60% of Part B drug costs, with per-patient treatments ranging from $100,000 to over $500,000.
The lack of a medical management framework in place led to over usage of mAbs. Key challenges included:
- Medical management: Authorizations for treatments that did not conform to evidence-based care or nationally recognized treatment pathways for dosage and frequency
- Biosimilar use: The plan did not leverage market-available biosimilars that were of lower-cost to administer
These challenges resulted in higher Part B spending for the Plan than when compared to their peers in the market.
Action
Sagility, which specializes in medical cost and utilization management, performed a population-specific medical spending analysis of the plan’s Part B drug spending and found that the plan’s higher spending was driven by several factors, primarily related to medical management and not leveraging available biosimilars. Sagility used its claims expertise and deep medical management acumen to align prescribing practices with standards-based care.
To capture the impact opportunity, Sagility applied a four-part approach that included:
- Clinical Policy Development: Applied evidence-based guidelines to support standards-based care and ensure treatment efficacy and appropriateness.
- Biosimilar Strategy: Encouraged biosimilar use for eligible patients, unlocking cost savings.
- Peer-to-Peer Education: Facilitated clinical discussions to align provider behavior.
- Complex Decision Support: Established a collaborative decision-making process to guide prescribers in using evidence-based treatment recommendations.
These steps helped the plan align care with clinical best practices, minimize unnecessary variation, and establish a foundation for sustained cost control.
Impact
Sagility’s strategy delivered measurable results, improving care quality while unlocking more than $11 million in potential savings. By applying clinical standards and supporting providers with education and decision tools, the plan established more consistent and cost-effective treatment programs.
Key outcomes included:
- More than $11 million in potential savings, driven by improved standards-based care.
- $1.2 million saved by converting to biosimilars.
- Implemented evidence-based treatment guidelines based on drug indication.
- Sustained prescribing improvements through peer collaboration and education.
Through thoughtful, evidence-based UM practices, Sagility helped the plan support members’ complex clinical needs while managing the financial realities of rising treatment costs.
in potential savings from improved standards-based care
saved by converting to biosimilars
