The goals of specialty pharmacy programs are to reduce or delay progression of the disease, improve patient outcomes, enhance patients’ quality of life, keep patients in the workforce longer, and decrease total health care costs.
As of January 2020, specialty drugs accounted for 39% of the total pharmacy benefit spend, which is expected to increase to almost 50% of total prescription spend by the end of the year. The specialty pharmacy industry is quickly expanding and its marketplace is expected to reach $400 billion in 2020.1
Currently, specialty medications are only used in approximately 1% to 2% of the population, but trends indicate that this utilization percentage will continue to rise. Seeing that high costs are associated with these medications and the magnitude of this increasing marketplace, it is important to examine what a specialty pharmacy is and the variety of important roles that it plays within this industry.
To begin, how do specialty medications differ from regular medications? There are many definitions of a specialty medication, but according to the Congressional Budget Office, “a specialty drug treats a chronic, complex, or rare condition and has at least 4 of the following 7 characteristics: cost at least $6000 per year in 2015; is initiated or maintained by a specialist; is administered by a health care professional; requires special handling in the supply chain; is associated with a patient payment-assistance program; is distributed through nontraditional channels, such as a specialty pharmacy; or requires monitoring or counseling.”3
A specialty pharmacy not only dispenses these specialty medications, but also provides a variety of enhanced pharmacy programs and services in addition to customized patient care. The disease states being treated in this population are often chronic, complex, or rare, as well as costly. Therefore, coordination, customization, and collaboration are vital in order to provide the best possible patient health outcomes.
The goals of specialty pharmacy clinical and patient management programs are to reduce or delay progression of the disease, improve patient outcomes, enhance patients’ quality of life, keep patients in the workforce longer, and decrease total health care costs. The tactics that are used to achieve these goals include promoting medication adherence, managing adverse effects (AEs), recognizing and responding to suboptimal responses to therapy, and proactively preventing complications.4
After a patient receives a diagnosis, their prescription is sent to the specialty pharmacy and the coordination of the patient’s care begins. Members of the specialty pharmacy team proactively reach out to the patient when they receive the prescription to schedule a consultation in which they discuss the treatment plan and, most importantly, address patient questions and concerns.
One of the largest concerns for patients, as well as third-party payers, is the high cost associated with specialty medications. The costs of these products could limit patients’ ability to afford their medication and could potentially delay initiation of therapy while care teams obtain prior authorization. To address the financial concerns, team members within a specialty pharmacy collaborate with the patients’ insurance company to explore formulary options, thereby ensuring there is no unnecessary delay in the initiation of therapy and to avoid an excessive financial burden for the patient.5
The drug and any necessary supplies are shipped to the patient and specialty pharmacy teams remain in close contact with the patient throughout their therapy. Pharmacists provide counseling, education, management of AEs, management of risk evaluation and mitigation strategy programs, adherence programs, screenings, monitoring of progression of the disease, and further coordination of care through collaboration with nurses, insurance and physicians. Since specialty pharmacies are in regular contact with patients and their physicians, they are able to relay updates to the physicians much more often and more regularly than if the patient and physician only discussed the treatment during their scheduled appointments.5
Specialty pharmacies have an essential role within this industry that is so much more than just the handling and dispensing of high cost medications. Through enhanced pharmacy services and programs, they are able to provide complete patient care through coordination, customization, and collaboration, ultimately leading to greater health outcomes for the patients and decreased costs to the health care system.
Cassian Widenhofer is a PharmD candidate at Duquesne University’s School of Pharmacy, anticipated to graduate in Spring 2021.Jonathan Ogurchak, PharmD, CSP, is the CEO and Co-Founder of STACK, a pharmacy compliance management software, and serves as preceptor for a virtual Advanced Pharmacy Practice Experiential Rotation for specialty pharmacy, during which this article was composed.