The Secret Is Out . . . Specialty Healthcare Is Here and Now

The American Journal of Pharmacy Benefits, Specialty Pharmacy, Volume 2, Issue 6

There is no universal agreement on what specialty pharmacy actually means and what products fall under its ever-expanding purview.

There is no universal agreement on what specialty pharmacy actually means and what products fall under its ever-expanding purview. We talk about it with our boss, we

complain about it to our chief financial

officer, and we try to figure out how to get it off our

expense record. Ask any of us and it is obvious—specialty

pharmacy is the elephant in the room. It is big,

really big.

Specialty pharmacy is part of specialty healthcare. However, when we ask our spouse or our children to define “specialty pharmacy” or even worse, “specialty healthcare,” their expressions go blank. My young adult children look at me bewildered and say something like, “Oh, it is something those specialists use, sort of, right?” We have kept it a secret from our own families! To an ordinary citizen, specialty healthcare or specialty pharmacy is from outer space. Yet from all indications, specialty pharmacy will allow the best care we can provide in the most remarkable ways. By the way, it will bankrupt us, too.

We need to clear the air.

Who will get these remarkable new therapies? Everyone? Only those patients with good insurance? Or, will a panel of experts decide which treatment goes to which person? These questions are just the beginning.

It seems as if specialty pharmacy has more in common with advances such as implantable pacemakers, devices for pain control, blood sugar monitors, and the like than with traditional pharmaceuticals or antibiotics. The marketplace does not fully understand specialty pharmacy products and how they will fit into our current treatment paradigms. To educate a payer on the importance of one of these products for a patient, substitute the name of that product for the name of an implantable device. The language is the same.

While we are sorting out issues related to what specialty pharmacy means and how it can help people, we need to address another issue—coding. There needs to be a way to code for these products so our computers can speak with one another intelligently. We have it backwards so far. We are using DNA testing to determine who may have these medications before we even have defined where these medications fit in our treatment and financial paradigms. Yes, we have some work to do.

When I got sick as a child, my mother took me to the doctor. At checkout, she paid the doctor and that was it. We went to the drugstore, where she paid cash for my medicine, and that was it, too. It was very simple. In college, I bought major medical insurance. I still had to pay for outpatient doctor visits, but if I needed surgery or hospitalization, it would be covered by insurance. As my family grew, I got full-coverage medical insurance and only paid a co-payment to see the doctor. Things got even better when my medicine was covered for the most part by insurance. Enter the new pharmacy benefit.

Ultimately, we all share the risk for specialty healthcare products and it may be our next insurance need. To quote Perry Cohen, PharmD, president of The Pharmacy Group, “There is a new tent out there just like the medical care tent or the pharmacy care tent, and it is called the specialty healthcare tent. It is here now and you can come inside and work out how it should look or not. Either way, it is here now and getting bigger every day” (Personal communication). The metaphor he provides will help us get something done. Either we decide our fate on this one or it will be decided for us.

The Pharmacy & Therapeutics Society is at the forefront of these changes. We are inside the specialty healthcare tent, and we want to see these products used in a rational and sustainable manner. It is time we step up collaboration with other like-minded individuals, companies, and organizations to determine how specialty healthcare can and should look in the future. We ask you to join us in this endeavor.