Michael R. Agostino, RPh, BSPharm

Specialty Pharmacy's New Frontier: Opportunities and Challenges for Retail

As technology continues to impact the way specialty pharmacists approach, deliver, and articulate specialized services to all stakeholders, there are a number of key considerations for entering the market.

While preparing a presentation for the National Association of Chain Drug Stores (NACDS) conference, one word continually comes to my mind when thinking about our niche profession. That word is “AMAZING.”

It is truly amazing how the need for specialized services continues to grow at such a fast pace every year. It is amazing how the specialty pharmacy market has accelerated its request for drug and channel management needs. It is especially amazing how technology continues to impact the way we approach, deliver, and articulate specialized services to all stakeholders.

I am always honored and humbled when given the opportunity to speak with my colleagues during NACDS. It is an outstanding conference and provides an excellent chance to reconnect with friends and business liaisons, listen to trends and industry updates, and form new relationships. Due to experience in both the retail and specialty pharmacy industries, I am able to view the specialty pharmacy industry from a unique vantage point and perspective.

First, let me say that I have never been more energized and excited about what is taking place within specialty pharmacy today. For those in retail pharmacy who are interested in taking the plunge into the specialty pharmacy arena, the market is moving and changing at lightning speed. With that said, there is still a lot of room in the market, but you have to move fast or you will be left behind! At the same time, you must take the time to do it right if you want to be successful.

Recently, I was invited to present to a group of professionals to assist with the launch of a new specialty medication. I had the opportunity to dive into the details of specialty pharmacy and provided the audience with 2 options: 1) View a detailed PowerPoint presentation, or 2) Allow me to share a story about an experience our staff recently had with a patient. Needless to say, they opted for the story. It is as follows:

A first fill referral for an oncology patient was sent to our pharmacist on a Wednesday and the patient’s therapy needed to start on Friday. Because of complications with the insurance, ordering the medication, and the Risk Evaluation and Mitigation Strategy (REMS) program associated with the medication, coordination of the order was not completed until Friday morning. The pharmacist discovered the patient lived close to our facility, so I delivered the medication and got to meet the patient and his dog.

Shortly thereafter, the next refill came in. The patient had new insurance and a prior authorization was required, which took longer than expected. Because the length of time between receiving the prescription and dispensing the prescription was greater than 7 days, the REMS program mandated that the physician send a new prescription. The physician was contacted and the patient’s daughter stopped by to pick up the prescription when it was ready. The staff that worked with her father had the chance to meet her and learn more about her dad and the family. With each order, staff was in constant contact with the patient’s daughter to provide status updates on his medication.

Soon thereafter, the patient’s daughter called to let us know the physician changed her dad’s regimen and the dose was tripled. Immediately, the pharmacist contacted the doctor’s office to request a new prescription so we could get the appropriate confirmation and quickly order the medication to be certain he received it in time for his next dose. The staff was just about to contact his daughter for delivery when we received a call from her. She was hysterical and wanted to speak directly with me. It was difficult to understand her because she was so upset. I quickly asked, “Please, tell me how I can help you.”

The patient’s daughter called to tell us that just minutes ago her father had passed away. She said the reason she called us first was to fulfill a promise she made to her dad. He made her promise that if something happened to him that she would call me directly to let us know how much he appreciated all of our help in getting his medication … and more importantly, caring about him. She said she had to keep her promise to her dad.

Specialty pharmacy can be defined by the interactions with patients that we experience. The heart of the profession lies in the stories of the patients whose lives we touch. If this type of unfailing commitment to the well-being of the patient doesn’t top your list of priorities, then specialty pharmacy may not be your calling.

Specialty pharmacy requires a great deal of hand holding, compassion, and caring. The following recommendations hopefully will provide some guidance if you are considering entering the specialty pharmacy market.

One of the most important questions you can ask yourself is “What services is your market in need of? What are they asking for?” The answer can be obtained by introducing yourself to surrounding specialists, physicians, nurses, hospital programs, and third-party plans. It is important to determine which patients—whether multiple sclerosis, hepatitis C virus, or HIV&mdash;hold a higher percentage within your market. Keep in mind the question that will always keep your business on the right track: “How can I help better serve my patients?” This simple question opens the doorway for communication and will ensure that your priorities are properly aligned.

THE TRUE MEANING OF A "SPECIALTY PHARMACY PROGRAM"

Within specialty pharmacy, a complete program incorporates an approach that satisfies all stakeholders. In this case, stakeholders are patients, providers, payers, and pharmaceutical manufacturers. For those in specialty pharmacy, one of the most important goals is to keep the process simple for the patient. This can be accomplished by putting yourself in the patient’s shoes. Imagine that you have just been diagnosed with cancer and your prescription order has been faxed to your approved specialty pharmacy. After calling your new specialty pharmacy you are welcomed with an automated phone system that offers you multiple options to press a number to speak with a person. How would this make you feel?

Ensuring that health care providers see value in our services is the key to specialty pharmacy’s success. This is accomplished through the creation of trusting relationships with all supportive staff, including case managers, nurses, and clinic staff. Once this connection is made, specialty pharmacy offers significant contributions when it comes to minimizing communication gaps along the patient care spectrum.

Each payer is different, but they all share common goals. Be prepared to ask tough questions. A great deal can be learned from striking the proper balance between asking the right questions and consultative advice. What you learn will become your opportunity to better serve and to offer your program. You need to be able to clearly articulate your therapy and management outcomes for the payer to recognize the value you have to offer.

We are currently experiencing profound change within the pharmaceutical manufacturing sector of health care delivery. Specialty pharmacy is becoming the first line for medication networks. The reason behind this change is that the majority of the pipeline of medications being delivered to the market is not going to be found within the retail delivery system, but within specialty pharmacy.

Unfortunately, our industry has been commoditized with pricing and service. One thing is for certain, the market is not tolerating this anymore. The level of accountability is rising very quickly for all stakeholders including the practice of pharmacy. When it comes to specialized pharmacy services, your value will quickly become diluted if you cannot clearly articulate your impact toward controlling costs and effective/appropriate patient care.

Get ready to invest capital. Once you have listened to your market and defined a service program, you will need to invest. A breakdown of where your investment needs to go will need to be presented to your executives. Expect to see a large portion of your investment in payroll, information technology infrastructure, and inventory.

While providing great service, there is always room for improvement. Keep this in mind as it is one commitment that will never let you down. Today’s approach to patient management is changing rapidly, especially within oncology. Oncology treatment of the past involved treating the form cancer or the type of cancer cell. Tomorrow’s cancer treatment involves attacking the pathway in which cancer thrives. Understanding the pathway has increased the importance of genomic testing. Genomic testing allows the confirmation for effective medication prescribing. Specialty pharmacy will play an important role, ultimately utilizing genomic outcomes as a confirmation to dispense and begin therapy management.

These changes within oncology are just one example of today’s rapidly changing approach to patient management. Flexible care management programs help to define your service model’s longevity within the market. These programs not only focus on meeting the needs of specific conditions, but specific medications as well. When you find yourself looking to get the latest updates on the specialty market, there is a high probability that you will gain more insight on the medication pipeline. This is where the rubber meets the road. You will need a sophisticated platform that allows your team to execute a best-in-class clinical management program.

The approach you take needs to offer a significant degree of flexibility. Flexibility in this case would be the ability to manage a specific condition down to a specific medication therapy management program. It is crucial that the system program has the power to collect all of the management data that your team inputs, allowing the ability to articulate the value and positive impact your care management program can offer. This communication about the value of your program is the most important aspect of data collection for specialty pharmacy and, candidly, where our industry is being held to a higher level of accountability. In other words, is it aggregated data presented in a flat file or is it data that are presented by a subject matter expert that takes the time to convey your developed program’s value to very expensive condition management opportunities?

Communication is not just about creating talking points and creative brochures for patients and caregivers. Solid communication is intentional and is meant to assist or inform in some way. Each target audience hears, reacts, and processes differently. The ability to reach out using multiple media tools and sources only broadens our ability to help key targets to understand what we are trying to convey. Clear, concise, and honest communication is a necessity for success in specialty pharmacy.

It is essential for specialty pharmacies to consistently send the correct messages to chronically ill patients and their caregivers. Contradictory information and inconsistent messaging can cause confusion and increase the levels of stress. There is already a lot to manage and to process across all touch points. Specialty pharmacies have to be exceptionally effective at sending out consistent messaging.

As you can see, based on these recommendations, the specialty pharmacy market consists of many different components, interactions, and moving parts from across the health care spectrum. Take your time to fully understand each of these components and the value specialty pharmacy can contribute to each sector. However, if you are going to act, act now. The market continues to change and grow at an accelerated rate, and now is the time to get your foot in the door. Make sure you can clearly articulate and communicate the value you have to offer and consistently follow up. And finally, when forging a path through all of the complications and complex interactions, let the well-being of the patient act as your compass to keep you properly aligned on the path to success.

Michael R. Agostino, RPh, BSPharm, is the president of Amber Pharmacy, an independent, family-owned provider of specialized pharmacy services headquartered in Omaha, Nebraska, with satellite locations in Dallas, Philadelphia, and Chicago. He is also president of Hy-Vee Pharmacy Solutions, an innovative joint venture between Amber Pharmacy and Hy-Vee, Inc. He holds a bachelor of science pharmacy degree from Northeastern University and serves on the board of advisors for Specialty Pharmacy Times and several nonprofit, economic, and community organizations.

Michael R. Agostino, RPh, BSPharm

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