Nick Calla, RPh, JD

This generation’s technologically savvy consumer behavior and drive to incite social change are unlike any generation that has come before. They consume more online content than any other generation, and they are texting more than ever. No, it’s not the Millennials. It’s the Baby Boomers.

The Baby Boomer generation is aging, but unlike any other generation before them. Throughout their lives, Baby Boomers have helped drive scientific innovation and embraced new technology to enhance their way of life, from the internet and cell phones to wearable technology and remote monitoring. As this new generation ages and requires more from health care providers, they will challenge existing stereotypes associated with older adults, such as being resistant to new ideas, slow to adapt, and highly dependent on others. These stereotypes are ubiquitous in our society and, when used by health care providers to determine treatment, can result in inappropriate or ineffectual care.

With an average of 10,000 people turning 65-years-old every day, understanding and meeting the changing needs of a new generation of older adults has never been more important. Furthermore, with 77 million members, there has never been a larger generation of older Americans than the Baby Boomers. Specialty pharmacies can play a critical role engaging with these older patients, but only if they are able to fully understand this generation’s needs, change their preconceived notions of aging, and deliver services designed to meet them where they are.

The sheer size of the Baby Boomer generation will stretch the resources of the US health care system, but their attitudes and behaviors will have an even greater impact on health care providers, forcing a reevaluation of the delivery of care. Currently between the ages of 52 and 70, the Baby Boomer generation can expect to live longer than their parents, but will also have higher rates of hypertension, diabetes, and obesity.

Additionally, this aging generation will add to the number of patients being treated for cancer, rheumatoid arthritis, and other chronic and complex diseases. Boomers will also be the most tech-savvy generation of older Americans ever.

		Boomers spend more time consuming online content than both Millennials and Generation X.

		81% of Boomers own a mobile phone, and 85% use it for texting.

		The internet is one of the first places Boomers go to conduct health research. 

While Boomers are technologically savvy, a digital divide exists between younger and older members of this generation. A 2012 study found that just 13% of Boomers over the age of 65 owned a smartphone, compared with 31% of Boomers aged between 55 and 64 years. This divide illustrates that while Boomers have always embraced new technology, they still have 1 foot in the analog world and 1 foot in digital.

They recognize the importance of new technology, but older Boomers may not be as “connected” as younger Boomers. Technology that supports health management and independent living will become particularly relevant as this generation ages. In a 

survey, 75% of Boomers said they intend to live in their current home for the rest of their lives. They want to age in place without burdening their children, while using technology to retain control of their lives and maintain their health.

Along with a changing generation, we are also seeing changing views on how age is defined. This has particularly significant implications for health care providers. When evaluating the age of older patients, the most common metric used is chronological age; however, chronological age alone does not provide a complete picture of a patient’s behavior, physical health, and lifestyle. “Functional age” takes all of these factors into account and presents a more comprehensive approach to assessing the needs of older patients.

		biological age, reflecting the patient’s physical health and genetic history

		psychological age, including the patient’s mental state and attitudes 

Classifying patients by functional age provides a more accurate measurement of their well-being. It can also help to determine the patient’s level of independence and the type of personal services they require.

Functionally older Boomers are less independent. They are interested in alternative care services, such as retail clinics and telehealth, but still value interaction with physicians, and may require more frequent monitoring and one-on-one engagement. Functionally younger Boomers are more independent. They are more likely to use remote monitoring and wearable devices, and they may prefer self-service programs that offer immediate access to information.

These patients will seek health care services with an Amazon-like experience: consumer-driven and interactive, with immediate access to information through apps and portals. While many health care providers are already considering functional age as a barometer for making care decisions, others, including many specialty pharmacies, are still using a one-size-fits-all approach to delivering care and services to patients based on chronological age alone.

The diversity of technology adoption and wide range of personal needs that exist within this generation demonstrates the need for specialty pharmacies to use functional age as a metric when determining the appropriate treatment options for older patients.

All of the players in the health care continuum will need to adapt their services to better support Baby Boomers as they age, particularly specialty pharmacies, because of the central role they play in connecting health care providers, drug manufacturers, payers, and patients. In order to succeed, specialty pharmacies will need to adapt in the following ways:

1) Identify and adopt tools to assess the functional age of patients

Identifying the functional age of patients starts with an accurate assessment at patient intake. Assessment tools exist today, but are not widely used. Going forward, leading specialty pharmacies will not only use such tools regularly with new patients, they will routinely monitor existing patients as well, ensuring that changes in functional age are taken into consideration throughout the care continuum.

2) Develop a continuum of services to meet the evolving needs of seniors 

Once functional age is established, specialty pharmacies will need to expand service offerings to better address the individual needs of seniors. As patients become functionally older, pharmacies will need to shift to services that deliver more one-on-one engagement, such as counseling and care coordination via phone with a pharmacy technician or patient support representative.

3) Enhance patient care through advances in technology

In the coming years, new health care technologies, such as robot companions, wearable and implantable medical devices, medicines with tracking sensors, and nursing home alternatives, such as portable housing units and smart homes, will provide older patients with smarter, more intelligent care that will enable seniors to remain independent longer. Specialty pharmacies will need to be early adopters of these technologies, as they will be used to support adherence and appropriate medication use. Additionally, they will also be instrumental in sharing the data collected from these devices with providers and manufacturers.

The Baby Boomer generation has driven change throughout its lifetime and, as they age, will challenge the existing stereotypes of frail, dependent seniors resistant to new ideas and advances in technology. These perceptions will need to shift in order to support a new generation of older adults, and help them manage complex diseases. The one-size-fits-all approach to treating older patients is no longer adequate.

By using functional age to determine a patient’s attitudes and level of independence, specialty pharmacists can continue playing a very relevant role in engaging with their patients. But, pharmacists will need to evolve the patient experience they provide to build an adaptable, personalized experience that meets these patients where they are.

, is the Vice President, Industry Relations for Cardinal Health Specialty Solutions. His previous experience includes roles as Vice President of Trade Relations for Community Specialty Pharmacy Network and President and General Manager of Oncology Pathways, a group purchasing organization founded by the UPMC Cancer Center and Medmark Specialty Pharmacy. His expertise includes compliance, disease management and intervention programs. He received a Bachelor of Pharmacy degree from the University of Pittsburgh, a Juris Doctorate from Duquesne University and has completed fellowship programs at the University of Pennsylvania, University of Southern California and Harvard University.

Articles

The Baby Boomer generation will stretch the resources of the US health care system, with technology-driven behaviors that force a reevaluation of the delivery of care.

Specialty Pharmacies and Baby Boomers: Adapting to Meet the Changing Needs of the New Older American 

Community-based specialty pharmacies are poised to set the trend for delivery of specialty drugs because of their emphasis on the personal care and patient management that help ensure positive outcomes.

While brand name products are declining in market share and the generic market is holding steady, another part of the pharmaceutical industry is rapidly rising and presenting new growth opportunities for pharmacy in the community setting. This is specialty products.

Specialty medications are used to treat complex and chronic conditions such as cancer, multiple sclerosis, and rheumatoid arthritis (RA). These drugs are typically high-priced—the average is $3000 per month. They also require significant coordination of care and typically have relatively complex data requirements involving the manufacturer. For example, hemophilia treatment can cost the patient and the health plan more than $500,000 per year in drug costs alone.

This segment of the industry continues to grow at a double-digit rate. For example, it is forecast that Humira, which is used to treat both RA and psoriatic arthritis, will be in the number 1 drug in the world by 2018. It is expected to have sales of better than $18 billion per year.

More companies are developing specialty drugs. According to a 2013 report of the Pharmaceutical Research and Manufacturers of America, 907 biologics were under development. Among these were 338 cancer therapies and 71 drugs for autoimmune disorders. And IMS Health indicates that specialty pharmacy is taking up a growing portion of new drug development. Of the 39 new drugs approved by the FDA last year, 30 were specialty drugs.

Community pharmacy has enjoyed great success in the marketplace and much praise from the health care community. The pharmacies in this setting have led the industry in maintaining a high level of patient compliance by counseling their patients to assist them in managing their particular disease(s).

Community-based specialty pharmacies are poised to represent a trend in the delivery of these products. These pharmacies consistently add significant value to the specialist and the patient by concentrating on the holistic delivery of both the product and the supportive care products. For example, the pharmacist is in a great position to coordinate the use of the oral chemotherapeutic agent and the products used to combat the typical side effects seen with these agents in cancer patients, such as nausea and neutropenia. Oncology is a complex disease state that requires this type of holistic approach to therapy to have an effective response to the drug regimen.

The most significant difference between community-based specialty pharmacy and the central fill specialty pharmacy has been the community pharmacy’s ability to provide expert and focused therapy management and related services in a face-to-face manner. Patient management has been a true value for specialty pharmacy. The fact that the community pharmacy can provide these services at a face-to-face level is coupled with the close relationship these pharmacies typically develop with the oncology practices in their respective areas.

Reimbursement is key to any pharmacy dispensing products costing an average of $3000 per month or more. The benefits the pharmacy can provide to the payer include the tracking of compliance and persistence and the ability to monitor price trends in these expensive disease states. Community pharmacy can take advantage of this trend by offering competitive services on products billed through the pharmacy billing systems.

The success of the specialty pharmacy model in controlling the cost and utilization of these products is what led the managed care industry to make expanded use of this model. The result is that this access provides an increasing opportunity for community pharmacy to participate in specialty pharmacy services and distribution for the oncology patient.

Community pharmacy needs to establish its value and niche in oncology practice to contract with plan sponsors and manufacturers to be included as a specialty pharmacy provider. Community pharmacy has long proved its value in the management of the HIV patient through face-to-face interaction and a close relationship with the provider. This model can be used to develop the same value proposition for the oncology patient as more products come to market in the oral space and the disease continues to be treated as a chronic condition.

Creating a Successful Specialty Practice 

To successfully create a specialty pharmacy practice, community specialty pharmacies will need to develop much closer associations with manufacturers of specialty products. These relationships will lead to better access and fee-for-service opportunities with the manufacturer. These services include but are not limited to:

The community pharmacy can share the benefit of its experience with the targeted patient population and can also help the manufacturer with prelaunch planning and ongoing decision-making. The ability to provide real-time, baseline data about the patient population, use of current therapies, and information on prescribers could offer keen insight that may not otherwise be available in a timely fashion.

Also, by having access to the patient’s entire drug history, the community pharmacy may provide the manufacturer partner with utilization and outcomes data to help trend the progress and issues of present and future medications. The ability to capture and share these data presents a unique opportunity for community pharmacy.

Another key advantage for community pharmacy is to be able to address issues for patients with multiple conditions, since patients treated with specialty products generally have multiple disease conditions. A disease management approach that addresses all the needs of a given patient would both enhance care and provide very effective management services for both the manufacturer and the plan sponsor. Here are some scenarios where this strategy would work:

		A combination of community pharmacy dispensing and central distribution of pharmacy order fulfillment for specialty medications within targeted disease states

		Clinical programs that will positively impact appropriateness and utilization and ensure proper compliance with and persistency to prescribed therapies

		Reimbursement support transparent to the community operation

		Ability to accept assignment of benefits for physicians and the payer

		Benefit design and formulary consulting

		Ability to provide immediate drug access to the patient 

Commitment to infrastructure, development of managed care organization relationships, and development of relationships with the manufacturer, as well as relationships with hub services offered by the manufacturers, will ensure a place in specialty therapy management for the community pharmacy. 

, is vice president of industry relations for the Community Specialty Pharmacy Network.

Specialty Pharmacy in Retail: A Face-to-Face Patient Experience

A specialty pharmacy is defined not by the site of care but the model of care and the type of services it provides to patients.

The Academy of Managed Care Pharmacy (AMCP) defines “specialty pharmacy” as follows:

“Specialty pharmacies are distinct from traditional pharmacies in coordinating many aspects of patient care and disease management. They are designed to efficiently deliver medications with special handling, storage, and distribution requirements with standardized processes that permit economies of scale. Specialty pharmacies are also designed to improve clinical and economic outcomes for patients with complex, often chronic and rare conditions, with close contact and management by clinicians. Health care professionals employed by specialty pharmacies provide patient education, help ensure appropriate medication use, promote adherence, and attempt to avoid unnecessary costs. Other support systems coordinate sharing of information among clinicians treating patients and help patients locate resources to provide financial assistance with out-of-pocket expenditures.”

	As Adam Fein has noted, AMCP is forced to acknowledge that “specialty pharmacy” reflects a pharmacy’s business decision, rather than a regulatory reality. A pharmacy can designate itself a “specialty pharmacy” if its business focus is self-administered specialty pharmaceuticals covered under a patient’s pharmacy insurance benefit. In addition to basic product dispensing, patients taking specialty medications often require more complex services than those required for a traditional drug.

	Although a majority of the specialty drugs that pharmacies dispense to patients are sold via a specialty pharmacy, any licensed pharmacy can dispense a specialty drug as long as the product can be purchased from a manufacturer or through an authorized wholesale distribution channel.

	We must note that a specialty pharmacy is defined by the type of services provided and not by the site of care. The majority of specialty pharmacy products today are handled by large central fill operations. This model has evolved over the past decade with prescription benefit managers and other managed care organizations building out specialty pharmacies within their organizations and then funneling the majority of their lives through these organizations. However, several large chains and independent operations have also developed over time. The key parameter in all of these operations is the notion of consistent clinical care of the patient with a complex disease state as well as the ability to capture complex data sets to support both the manufacturer and the managed care entity.

	As the specialty boom continues, we expect this market of products will top $200 million in annual sales by 2018. Clearly, this is a large market and other models of specialty pharmacies need to be considered. The independent pharmacy community and the small to mid-sized chain community are developing their own models to care for the specialty patient. I believe there is plenty of room in the market to build out these models. The key, as stated above, is consistent clinical practice, as well as consistent data capture ability. It is incumbent on the decision makers in these spaces to create a focused plan designed to meet the demands of the specialty pharmacy product and patient.

	There are several models in development now. Community Specialty Pharmacy Network was created to manage independent community-based pharmacies that have entered the specialty pharmacy space with their data management and consistent clinical care capabilities. Cardinal Health recently introduced an initiative termed the “Specialty Pharmacy Alliance,” which is a support center for pharmacies that have a specialty patient in their practice but have not developed the infrastructure to effectively manage that patient. This back-end support center can handle the prior authorization and reimbursement support previously mentioned.

	Finally, many chains have launched specialty initiatives designed to support the patient who enters the pharmacy by utilizing central support mechanisms, either developed internally such as Walgreens has done, or by outsourcing this function to an independent central-fill operation such as Diplomat Specialty Pharmacy located in Flint, Michigan.

	In the end, what really matter in specialty pharmacy are the services provided to support patient, provider, payer, and manufacturer. The support must be consistent and the systems utilized sophisticated enough to meet the needs of all the constituents. It is not the site of care that is important, but the consistency and quality of the services provided.

Nicodemo “Nick” Calla, RPh, JD, is vice president of industry relations for the Community Specialty Pharmacy Network.