Oncology: An Ever-Growing Presence in Specialty Pharmacy

Specialty Pharmacy Times, May/June 2015, Volume 6, Issue 3

As oncology spending rises, insurers and manufacturers are looking to specialty pharmacy programs to maximize the effectiveness of cancer therapies.

As oncology spending rises, insurers and manufacturers are looking to specialty pharmacy programs to maximize the effectiveness of cancer therapies.

Welcome to our fifth oncology-focused edition of Specialty Pharmacy Times. Earlier diagnosis, longer treatment duration, and increased effectiveness of drug therapies are contributing to rising levels of spending on medicines for cancer care. At the May 2015 Armada Specialty Pharmacy Summit, most of the presentations on specialty included a discussion of cancer. One of the speakers discussed a recent report released by the IMS Institute for Healthcare Informatics, which revealed that total global spending on oncologic drugs, including both therapeutic treatments and supportive care, exceeded $100 billion in 2014. In the United States, oncology spending grew slightly, however: from 10.7% to 11.3%. Meanwhile, spending on targeted therapies has grown to account for nearly 50% of total spending, with a 14.6% compound annual growth rate since 2009. Targeted therapies have also risen double digits during the past 5 years, with steady increases in all regions of the world, dramatically increasing their share of the total oncology spend.

The majority of oral oncology products in the United States are dispensed by specialty pharmacies. As the debate rages among payers and health systems over the value and benefits of high-cost specialty drugs compared with existing treatments, patient access to these treatments is frequently limited. With the drug pipeline filled with individual and combination oncologic therapies that address multiple cancer types, issues related to cost and access will remain crucial to oncology stakeholders in the coming years. The need to achieve maximum effectiveness from therapies will be a priority.

According to IMS, over the past decade, the cost per month for the average oncology therapy has grown 39% in the United States in inflation-adjusted terms. Patient response rates improved by 42% over that timeframe, while treatment duration increased by 45%. The by-product of these gains in survival has been an increased cost burden on the patients using high-cost cancer drugs. Out-of-pocket costs for intravenous cancer drugs jumped by 71% from 2012 to 2013, which reflects changing plan designs and increasing costs for outpatient facilities. Specialty pharmacies are experts at obtaining reimbursement for high-cost products. Most specialty pharmacies offer patients assistance in locating reimbursement support programs.

With these rising trends, it is clear that any stakeholder in pharmacy must take on oncology as a key driver of their practice. Equally clear is why the payer-owned specialty pharmacies are focused on the oncology category and, more often than not, require a rigorous approval process that directs oncology prescriptions to their own in-house specialty pharmacy. It is a matter of sheer economics.

OPEN AND LIMITED DISTRIBUTION ONCOLOGY PRODUCTS

Not all products are limited in their distribution; many significant oncology products have open distribution. In the case of limited distribution products, however, the manufacturer often performs a search for 1 or more specialty pharmacies that meet an established criterion for inclusion in a network of qualified candidates. Optimally, the manufacturer uses an objective scoring process based on established criteria and the needs of their particular oncology product to assure an optimal patient outcome, as well as a fair market value assessment to assure that any pricing has a bona fide service fee. To ensure patient access, the manufacturer will want to understand the specialty pharmacy’s experience at obtaining payer coverage, particularly if the pharmacy is not tied to a payer. If the pharmacy is tied to a payer, the manufacturers will want to see how successful the pharmacy has been in securing coverage from other payers.

With the rising costs of oncology products and the increasing number of excellent agents, the successful execution of a reimbursement plan is essential. In the absence of such a plan, many manufacturers are compelled to offer patient assistance programs, which are costly to administer and detract from profitability.

ADHERENCE: SPECIALTY’S VALUE PROPOSITION

Equally important for the manufacturer should be a specialty pharmacy’s ability to educate patients about their oncology care and improve their adherence to therapy. Effective programs can lead to improved adherence behavior and substantial reductions in overall medical costs. Critical steps in improving adherence through case management include:

  • Identifying patient behaviors and needs
  • Understanding why patients behave as they do and what drives their needs
  • Gaining insight into disease management challenges
  • Gaining insight into treatment challenges
  • Developing a strategic and tactical patient adherence program

By far, a therapy adherence program is the most meaningful service a specialty pharmacy can offer to a patient. Services often include a combination of education, check-in programs, refill reminders, unique dispensing platforms, and technology.

Employers and insurers are weighing investments in specialty pharmacy programs with an integrated approach to clinical management for cancer patients to improve outcomes and reduce costs. A well-trained specialty pharmacy team can offer the patient a holistic portfolio of services for their oncology products and other critical medications and therapies. SPT

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About the Author

Dan Steiber, RPh, is a founder of D2 Pharma Consulting LLC (d2rx.com) and is responsible for commercial operations, trade-supply chain strategy development including 3PL selection, regulatory oversight, and “operationalizing” organizations. He has served in several senior positions in pharmacy, distribution, and industry over the course of his 40-year career. Mr. Steiber is a licensed pharmacist in Texas, Washington, California, and Pennsylvania. He is affiliated with several professional associations and publications and is a frequent speaker on behalf of many professional organizations. He graduated from Washington State University College of Pharmacy and has participated in a variety of postgraduate programs in law and business development/marketing at Harvard University and Northwestern University. Dan currently resides in Highland Village, Texas.