Significant growth has been seen in specialty medication use in long-term care facilities.


The specialty drug trend is not only increasing in the community setting, but also among pharmacies that service patients (ie, residents) who live in senior-care settings such as long-term care (LTC) facilities. The 2015 Managed Health Care Associates (MHA) Independent Long Term Care Member Study1 included a section on specialty medications, which consisted of an analysis of LTC pharmacy dispensing data.

Although this is MHA’s fifth year looking at specialty within LTC, due to methodology changes (including short-cycle dispensing requirements), results cannot be compared with studies conducted in prior years. This year’s study periods included an analysis of data from January 1, 2013, to September 30, 2013 (study period 2014), compared with January 1, 2014, to September 30, 2014 (study period 2015). The analysis included claims data from 1145 pharmacies encompassing over 169 million claims. More than 3 million patients from all 50 states were represented in the study. This article will examine some overall trends as well as take a deeper dive into specific therapeutic categories.

Overall Trends
The results from this study illustrated that LTC pharmacies included in the analysis have seen:
  • Significant growth among select specialty categories within LTC pharmacies
  • 289% increase in the utilization of medications used to treat hepatitis C virus (HCV), mirroring the growth trend for HCV in pharmacy as a whole
  • 29% increase in medications used to treat inflammatory conditions, including rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis (UC), psoriasis, and psoriatic arthritis
  • 27% growth in the use of medications to treat multiple sclerosis (MS)
  • 11% increase in the use of injectable osteoporosis medications
  • 7% increase in the use of medications to treat HIV
  • Relatively stable utilization among oncology products, with a 3% growth in the oncology self-injectable products and a 2% decrease in oral oncology products (Figure 1).
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Multiple Sclerosis

MS therapies within the LTC pharmacies studied showed an overall growth of 27% for the 2015 study period. Copaxone (glatiramer acetate subcutaneous injection), the various dosage forms of Rebif (interferon beta-1a subcutaneous injection), and Extavia (interferon beta-1b subcutaneous injection) posted the largest percentage increases. Rebif is now the most-used MS drug in the LTC setting by prescription count, overtaking Copaxone for the first time in the MHA study. Top MS therapies with sustained or increased growth in prescription count in LTC from the 2014 to 2015 study period include:
  • Copaxone (glatiramer acetate)
  • Extavia (interferon beta-1b)
  • Gilenya (fingolimod)
  • Rebif (interferon beta-1a)
The newer oral disease-modifying agents for the treatment of MS, Aubagio (teriflunomide), approved in September 2012, and Tecfidera (dimethyl fumarate), approved in March 2013, continue to have minimal use in the LTC setting. The reason for this may be due to the fact that they are only available via limited distribution through preferred specialty pharmacies. Recently approved agents Plegridy (peginterferon beta-1a), which was approved by the FDA in August 2014, and Lemtrada (alemtuzumab), which was approved for use in the United States in November 2014, were not included in this analysis.

Internal medicine and general practice prescribers continue to be the leading prescriber groups who are writing prescriptions for MS treatments for patients in LTC facilities, as evidenced in this study. This year also marks a significant growth in neurologists prescribing MS medications in the LTC pharmacy market. In this study period, neurologists constituted 25% of all prescribed MS medications compared with 9% in the 2014 study period (Figure 2).



Inflammatory Conditions
Biologics for inflammatory conditions also posted significant growth of 29% in the 2015 study. These products are used to treat diseases such as rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease, UC, psoriasis, and psoriatic arthritis. Year-over-year growth in prescription count was noted for each of the following:
  • Actemra (tocilizumab)
  • Cimzia (certolizumab pegol)
  • Enbrel (etanercept)
  • Humira (adalimumab)
  • Ilaris (canakinumab)
  • Kineret (anakinra)
  • Orencia (abatacept)
  • Otezla (apremilast)
  • Otrexup (methotrexate)
  • Remicade (infliximab)
  • Simponi (golimumab)
  • Stelara (ustekinumab)
  • Xeljanz (tofacitinib)
Internal medicine, general practice, and rheumatology prescribers continue to be the lead specialties writing for biologics in LTC facilities as seen in this study (Figure 3).



Hepatitis C
Use of medications to treat HCV rose significantly (289%) in the LTC study population between the 2014 and 2015 study periods due to the introduction of Sovaldi (sofosbuvir) and Olysio (simeprevir). This trend mirrors overall trends in this therapeutic class as Express Scripts Lab Insights estimates that by 2016, spend on HCV treatments will exceed that of more common illnesses such as hypertension and hyperlipidemia.2 With the introduction of Harvoni (ledipasvir and sofobuvir combination) approved in October 2014 and Viekira Pak (ombitasvir, paritaprevir, and ritonavir with dasabuvir) approved in December 2014, it is anticipated that utilization in this category will continue to increase for the newer agents and decrease for the older therapies as treatment guidelines and practices continue to evolve (Figure 4). Gastroenterologists lead the prescribing of HCV medications, accounting for 40% of the prescribed medications.



Oncology
The trend in oncology in the 2015 study showed relatively stable utilization of oncology products with a 3% growth in oncology self-injectable products and a 2% decrease in oral oncology products in the LTC setting. The growth in oncology self-injectable products was primarily driven by Sylatron (peginterferon alfa-2b), Trelstar (triptorelin pamoate), and Yervoy (ipilimumab). Although overall growth dipped slightly in the oral oncology space, there was significant growth in many branded oral oncology agents from the 2014 study period to the 2015 study period. Among the branded agents experiencing growth in the LTC space:
  • Afinitor (everolimus)
  • Bosulif (bosutinib)
  • Erivedge (vismodegib)
  • Imbruvica (ibrutinib)
  • Pomalyst (pomalidomide)
  • Tafinlar (dabrafenib)
  • Tasigna (nilotinib)
  • Votrient (pazopanib)
  • Zelboraf (vemurafenib)
  • Zytiga (abiraterone acetate)
Prescribing for oral oncology products was driven by internal medicine, representing 41% of prescribers. General practice accounted for 33%, and oncologists prescribed 5% of the prescriptions in the oral oncology therapeutic category to LTC residents.


HIV
Prescriptions for HIV therapies in the LTC pharmacy market grew by 7% from the 2014 to the 2015 study period. This may reflect the fact that a growing number of people 55 years and older are living with HIV. The Centers for Disease Control and Prevention estimates that persons 55 years and older accounted for 26% of the people living with HIV in the United States in 2011.3 In addition, older Americans are more likely than younger people to be diagnosed with HIV later in the course of their disease, meaning a delayed start to treatment and potentially more damage to their immune system. This represents a potential opportunity for LTC facilities specializing in HIV/AIDS treatment.

Specialty Services in LTC
Although the average number of specialty prescriptions dispensed per LTC pharmacy per month remained relatively constant from the 2014 to the 2015 study period, the total specialty pharmaceutical spend increased significantly in that time period. This is thought to be driven in large part by the significant increase in HCV drugs, namely Solvaldi (sofosbuvir) and Olysio (simeprevir). It is anticipated that spend of specialty pharmaceuticals within LTC will continue to rise significantly with the addition of Harvoni (ledipasvir and sofobuvir) and Viekira Pak (ombitasvir, paritaprevir, and ritonavir with dasabuvir) to the marketplace (Figure 5.)



In addition, the percentage of prescriptions dispensed with a co-pay for specialty pharmaceutical products within the LTC setting increased slightly from 33% in 2014 to 36% in 2015 (Figure 6). When the patient did experience a co-pay, the average per specialty prescription dispense was found to be $168 in 2014.



Despite challenges such as limited distribution, preferred or narrow specialty pharmacy payer networks, and compliance with Risk Evaluation and Mitigation Strategies program requirements, this data confirm that LTC pharmacies are increasingly providing specialty pharmaceuticals to patients across all LTC settings. Providing high-quality, accessible, specialty pharmacy services to facilities that care for these patients is of the utmost importance as the population in the United States ages. SPT

The above information is a selective summary of publicly available information and is accurate as of the date of writing. Please consult the sources for complete reference information. The views expressed in this article are those of the authors alone and not of Managed Health Care Associates, Inc.

References
  1. MHA Independent Long Term Care Member Study, 2015. Managed Healthcare Associates Inc. Available upon request at MHALongTermCare@mhainc.com.
  2. Facts and figures: specialty infographic provided by Accredo, Express Scripts: hep C kills 15,000 Americans each year – more than HIV. J Manag Care Pharm. 2014;20(2):109. Published February 2014. Accessed June 3, 2015.
  3. HIV among people aged 50 and older. Centers for Disease Control and Prevention website. www.cdc.gov/hiv/risk/age/olderamericans/. Published May 12, 2015. Accessed June 3, 2015.


About the Authors
Kimberly Binaso, PharmD, RPh, CCP, FASCP, CGP, FASHP, is currently the vice president of Clinical Services for Managed Healthcare Associates, a health care services organization located in Florham Park, New Jersey. Dr. Binaso is a certified consultant pharmacist in the state of New Jersey, a fellow of both the American Society of Consultant Pharmacists and the American Society of Health Systems Pharmacists, and a board certified geriatric pharmacist). For the past 15 years, she has held several clinical management and leadership positions working extensively with both consultant and clinical pharmacist teams in senior care. She is an active member of The American Society of Consultant Pharmacists, The American Society of Health Systems Pharmacists, and the American Medical Directors Association. Dr. Binaso serves as a national visiting professor and senior care expert presenter contributing posters and articles on a variety of geriatric clinical issues.




Stacey Ness, PharmD, RPh, CSP, MSCS, AAHIVP, has worked in both national specialty pharmacy and payer organizations and has experience in clinical management, adherence and persistency programs, and chronic disease cost optimization strategies. Dr. Ness is active in the Consortium of Multiple Sclerosis Centers, the Academy of Managed Care Pharmacy, the National Home Infusion Association, the National Association of Specialty Pharmacy, the Specialty Pharmacy Certification Board, and the Hematology and Oncology Pharmacy Association, and has served on the Minnesota Medicaid Drug Formulary Committee since 2008. She is a multiple sclerosis certified specialist, a credentialed HIV pharmacist, a certified specialty pharmacist, and currently serves as the director of specialty clinical services at Managed Health Care Associates, Inc, a health care services organization based in Florham Park, New Jersey.