A Specialty Pharmacy Chronicle: The Driver, the Journey and Stops Along the Way

Specialty pharmacies play a vital role in the patient journey from diagnosis to treatment.

The experience — part I

For months now, you have been experiencing a range of gastrointestinal (GI) symptoms. It started with inconsistent bloating and abdominal discomfort, but recently, you have noticed a considerable amount of weight loss without diet or exercise.

Something is wrong, but you really don’t feel ill. It’s time to call your primary care physician.

As you sit in the physician’s waiting room, pondering what will come about from the visit, your name is called. In the examination room, the flurry of questions begins—we all know this experience.

After your nurse gathers all the necessary information, she heads out the door stating those famous last words: “The doctor will be with you in a few minutes.”

Twenty-five minutes go by and there is a knock at the door as your physician has arrived. He inquires as to the nature of your visit, which at this point you are eager to share.

Following the discussion and exam, he is confident as to what may be the problem.

“Your prescriptions will be sent to your local pharmacy,” he states. “Take these medications and call me in a month.”

With some pep in your step, out of the physician’s office and straight to the pharmacy you go. Here, your friendly pharmacist counsels you on the cocktail of GI-related medications that the doctor has sent in. As the compliant patient you are, you start treatment immediately.

A month has now passed and not only are you almost out of medication, but you’re feeling worse. As directed by your doctor, you place a phone call to the office and inform the nurse of what has transpired. They want to see you right away.

You arrive to the office and the doctor is waiting for you. This time, you notice the exam and assessment are more comprehensive. He is asking different questions and performing different techniques.

Feeling confused and uneasy, you ask, “which medications will it be this time doctor?”

“This time, there will be no prescribing of medications. Instead, I am referring you to a specialist,” he says. As the anxiety runs rampant in your body, you reply, “a who and what for?”

At this point, your physician’s intuition and experience takes over. By referring you to a specialist, your physician believes that this is either out of his scope of practice, more serious than initially thought, or both.

The specialty experience — part II

Your appointment with the specialist, a gastroenterologist, has finally arrived. You cannot help but to wonder what you are really in for and why you’re there. Nonetheless, you are hopeful that the specialist has the solutions to your problem.

The moment has arrived and the physician walks in the door. After a discussion with your new physician, she indicates that she may be able to help. In exuberance, you state “doctor, what do you think this is and I am going to be ok, right?”

She indicates that it may be a form of irritable bowel disease and would like to perform additional testing to confirm.

Taken back and scared, your mind begins racing with thoughts. “Doctor, what is irritable bowel syndrome? What does it mean to my life? Please help me.”

The driver and the journey

The next few months would prove to be something that you never anticipated. You are consumed with the process and the requirements by your physician.

It begins with the need for blood draws and the ensuing results prompts the need for another appointment with the physician. During the appointment, you inform the physician that you are worsening.

You have lost 35 pounds in 4 months without trying to and you are always fatigued, regardless of how much sleep you get. You average 5 trips per day to the restroom...life has changed completely.

The physician discusses the abnormalities found in your lab results and, in combination with clinical worsening, she recommends a full exploration of the upper and lower gut along with your intestines. It is not something that you are eager to do but you are desperate for answers and agree to it.

Following the procedure, the physician informs you of her findings. There are 3 ulcerations within your intestines and moderate inflammation throughout the upper GI tract. Furthermore, in order to provide a definitive diagnosis, she recommends that 2 additional procedures are needed.

How much more will you have to endure?

The specialty experience — part III

Six months have passed since your first appointment with your primary care physician. Life has left you feeling like an experiment; you are physically, mentally, and emotionally exhausted. Today is the day though!

The gastroenterologist called you a week ago requesting to discuss the findings from all the testing. She enters the room, expressionless and reserved. The diagnosis is definitive, moderate-to-severe Crohn disease.

Your heart sinks into your stomach, as you break out into a cold sweat. Silence fills the room, as you struggle to compose yourself. In that moment, the physician begins to discuss the prognosis, the expectations, and most importantly, the next step.

Given the severity of your disease, she recommends starting treatment with a disease modifying anti-rheumatic drug (DMARD). Your physician prescribes a medication called Imuran; still in shock, you are amendable to anything that will help.

Treatment begins immediately and after 2 weeks, you begin experiencing severe stiffness in your joints. Unsure of what could be the cause, you place a call to your physician’s office. She informs you that this is a rare side effect from the medication and to discontinue use immediately as a new medication is prescribed, methotrexate.

Six months have passed since you started on methotrexate and you are feeling the best you have in 2 years. During a routine follow up call with your physician, she explains the need for a colonoscopy to be performed.

It has been some time since that last procedure and she wants to observe whether there is disease activity. While you did not embrace the recommendation with open arms, you agreed to it.

The unexpected

One week preceding the scheduled procedure, your day starts as normal. You arrive to work unknowing and unsuspecting of what the day holds. You find yourself working diligently up until lunch.

As you sit down to enjoy your food, it almost feels like you just ate. Without thinking about it, you finish your lunch and at about mid-day, you begin feeling uneasy. Some mild pain and abdominal discomfort are making it hard to focus.

Close to the end of the shift, the pain and discomfort have intensified beyond tolerance. Not having any prior experience such as this, you manage to drive yourself to the emergency room. The pain is indescribable by the time you arrive, allowing you to be quickly triaged to a room.

After limited conversation with the attending physician, she recommends an MRI of the abdomen. The findings show a small bowel obstruction and treatment is initiated.

This episode causes you to spend 5 days in the hospital. During those days, your gastroenterologist is at the forefront of your care. The MRI results showed disease progression and it is time for a more effective medication—Humira, a specialty medication, is the drug of choice.

Prior to this, you have never heard of specialty medications. It was yet another new endeavor to become familiar with.

“What is a specialty medication, doctor? Is it a cure? Can I just get it at my local pharmacy? Is it expensive? What happens next and what does it involve?”

So many new questions to be answered.

We all play a part in the journey

The journey that a patient embarks on, leading up to a specialty disease diagnosis, is exhausting; what you just read, reaffirms this. It is not as simple of 2 physician visits, diagnosis given, specialty medication prescribed, and treatment started.

Yet, for most of us who have never gone through or witnessed the process first-hand, it is easy to overlook it. If this describes you, then now is an opportunity to learn the vital role you play within a patient’s journey.

It all begins with the patient, the driver of what we do and why we do it. The patient’s copilot is the prescriber. They play the most critical role in navigating patients down the most appropriate path to better health.

As we are aware, the ability to treat a patient is limited by the availability of medications on the market. Through innovative technology, research, and development, manufacturers have been able to produce life-changing medications known as specialty medications.

Specialty medications are in a league of their own and for good reasons. They are extremely effective in doing what they are intended to do. That being said, they also carry higher risks than non-specialty medications and an inherent need for clinical monitoring throughout the duration of therapy.

Health plans and payers often find themselves caught in the middle of the patient journey. Acting on behalf of the plan sponsors they serve, it is their responsibility to ensure specialty medication utilization is in accordance with evidence-based guidelines due to cost. Unfortunately, applying due diligence can be time consuming, resulting in a delay of all the processes that follow.

Specialty pharmacies may have the most dynamic role within the patient journey. Considered the “gatekeepers” of the industry, specialty pharmacists wear many different hats in order to accomplish different tasks all on behalf of the patient.

Obtaining access from a manufacturer for a specialty medication is the element that drives everything else. Therefore, specialty pharmacies must demonstrate that their clinical management programs are robust enough to meet the requirements that any given medication may have and be awarded a contract.

Specialty pharmacies must also build trust with prescribing physicians who are elite providers of care and any willing partner will be held to the same standard. Therefore, a specialty pharmacy that can demonstrate their ability to be an asset will quickly gain the confidence of a prescribing physician.

Relative to payers, partnerships are determined, driven by performance, pricing-based contracts, and the ability of a specialty pharmacy to meet these contractual obligations.

Lastly, is the most important partnership of a specialty pharmacy and the driver of the business we are in—the patient. Patients value relationships above all else; they want to have a connection with their pharmacy and feel cared for.

When a patient is prescribed a specialty medication, the first contact made to the patient is done by the specialty pharmacy. After the medication is approved by the payer, the next contact to the patient is by the specialty pharmacy. When the refill for the medication is due, the specialty pharmacy will again contact the patient.

Are you catching my drift yet?

There is no single party that is more important than the next within the patient journey. When all parties involved are working together, it creates an environment that develops relationships premised on trust, reinforced by compassion, and solidified by the desire to achieve the same goal: improving the quality of life for our patients.

About the Author

Joe Thomas earned his Doctor of Pharmacy degree from Duquesne University and is currently enrolled in the Masters of Science in Pharmacy Business Administration (MSPBA) program at the University of Pittsburgh, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines. He has spent the past several years working across several specialty pharmacies, integrated in both staff- and corporate-experiences.