Specialty Pharmacy: Why Does It Take So Long?
Multiple specialty pharmacy processes can delay the time-to-fill for specialty medications.
As a specialty pharmacist, I have been faced with countless questions from new patients concerning the difference between specialty pharmacy and community pharmacy, as well as countless complaints about the process. During these instances, I take the time to explain specialty pharmacy, defend the honor of specialty pharmacy, and educate patients and prescribers alike on the specialty pharmacy process.
Today, I have a firm grasp on this process and the reasons why receiving a specialty medication often takes significantly longer than non-specialty medications. However, in the past, I frequently stumbled to answer such questions, skirting around the answers and providing less than satisfactory responses.
A routine phone call will periodically bring to surface this dissatisfaction, such as length of time to dispense and deliver medications, necessity to ask extensive and sometimes probing questions, the need to obtain specific clinical information from prescriber offices, and the high price tags on many of the prescriptions, to name a few. This confusion and dissatisfaction is all too common in specialty pharmacy.
Sometimes, a patient who previously went to a community location or a prescriber who has little experience with a specialty pharmacy does not understand why a retail pharmacy can have a prescription ready in 15 minutes; however, the industry standard for new patients in specialty pharmacy is 14 to 20 days. I want to help answer these questions and help other pharmacists understand why does it take so long?
New Patients—From Intake to Outtake
As a pharmacist with a retail background, I could enter the data for a script, receive a paid claim, grab a bottle off the shelf, use a spatula to count out 30 Atenolol tablets, and verify that script for pick up in a matter of seconds. That is by no means to suggest that retail pharmacy is easy.
A retail pharmacist also has thousands of phone calls, thousands of customers, and thousands of other prescriptions, all needing that same process done. In fact, the most time intensive factor in a specialty pharmacy, the face-to-face patient interaction, is often times nonexistent. Again, begging the question why does it take so long?
That question can be answered by explaining all of the different hands that are in the cookie jar at the same time. As such, the process to move a prescription from intake, through the system, and to the patient is significantly more complicated.
There are teams of customer service representatives, insurance specialists, technicians for data entry, technicians in drug fulfillment spaces, pharmacists working in those same drug fulfillment spaces, pharmacists working in offices, supervisors, IT specialists, human resources—I think you get the picture—often all working under the same roof.
Furthermore, there are payer contracts, specialty pharmacy accreditation boards, clinical data collection requirements, limited distribution networks, state shipping limits, and myriad other hurdles that specialty pharmacies must clear in order to deliver that product. When all of these are added up, the slow time-to-fill process starts to make a little bit more sense.
Starting the Process
The patient “journey” is currently a buzzword within the pharmacy industry, and no matter your opinion on buzzwords, considering the patient journey helps to assemble the pieces of this puzzling process. With that in mind, consider the patient’s initial diagnosis and receipt of first prescription.
Specialty medications are often used to treat and manage patients who take very expensive or high-touch drugs, patients with more severe disease states that require closer clinical monitoring, or a combination thereof. Therefore, a patient may initially see a Primary Care Physician for an issue and then be referred to a disease state specialist.
This specialist may then have to do some follow-up or testing, make a diagnosis, and possibly prescribe a medication. At this point, the patient has most likely already been involved in a costly and lengthy process.
Once the prescription is finally written, the next question becomes which pharmacy to use. Sometimes this prescription may initially be sent to retail who then must determine whether they can obtain and fill the prescription.
In other cases, the prescription may be sent to a specialty pharmacy who may or may not be able to fill it, due to insurance or distribution limitations. The process of getting the prescription to the correct pharmacy can be a particularly lengthy.
Once a specialty pharmacy receives a prescription, they must then enter the prescription data into their computer system and determine whether they can service and fill the medication for the patient.
This step is sometimes repeated if the prescription bounces around from one pharmacy to another during the process. In these instances, one of two things may be occurring.
First, a pharmacy benefits manager (PBM) has excluded certain specialty pharmacies from a network, only allowing specific pharmacies to service patients with that insurance. Secondly, a manufacturer could have created a limited distribution network for a medication, again allowing only certain pharmacies to dispense.
The prescriber and patient are often ignorant of these specifications, further adding to the time it takes for a patient to receive treatment. Only when the correct specialty pharmacy receives this new prescription for a patient does the 14- to 20-day clock start to tick.
Normally, a specialty pharmacy will have technicians or clerical staff to view new faxes and prescriptions, sort them, and enter necessary new referrals and prescriptions into the pharmacy computer system. This is usually where first contact with the patient is made.
The patient will be advised that the prescription is received and additional insurance work needs to be completed before the medication can be shipped.
The insurance department will then shortly be notified to determine a patient’s coverage and work to get a paid claim for a prescription. Again, this is a time-consuming process.
Because of the high cost of many specialty medications, insurance companies often require prior authorizations. Therefore, the prescriber must be notified and submit necessary medical information to the insurance company, which again adds to the time-to-fill.
If the patient’s insurance does cover the prescription to some degree, there are other departments who will work to obtain funding or assistance for cases in which the patient cannot afford treatment.
Grants, manufacturer co-pay assistance, certain government funding, etc, are all available to help patients pay for medications that would otherwise be too expensive.
Those Pesky Pharmacists
Somewhere along the line, pharmacists are also involved in this process. Pharmacists ensure that the prescription is clinically appropriate and safe for use, rubber stamping a final okay before anything can leave the building.
Pharmacists often need to obtain necessary clinical data, inquire about proper patient titration dosages, clarify treatment cycles for patients, and receive other basic information. The information necessary to dispense a specialty medication is regularly more complex than for non-specialty medications, and obtaining these clarifications can also be time consuming.
For example, a pharmacist may want to obtain patient height and weight to ensure growth hormone therapy is appropriate. Another pharmacist may want to notate hepatitis C clinical data, such as treatment duration, genotype, and cirrhosis status.
A third pharmacist may be trying to obtain site of injection and frequency for a prescription written for Botox. Finally, a fourth pharmacist may be working to relay information to a prescriber’s office about registering for risk evaluation and mitigation strategies (REMS)-related requirements before a prescription can be dispensed.
Whether these reasons for additional clarification are clinical in nature, a necessity for insurance contracts, a concern about auditing, or a requirement for government REMS programs, prescriptions in these cases may be delayed. The line between allowing a prescription to leave the pharmacy without clarification for the betterment of the patient versus holding a prescription to obtain clarification, becomes more blurred and complicated every day.
After all the previous steps have been accomplished, most pharmacies will need to obtain and solidify any other necessary patient information. The patient will provide missing demographic information, confirm co-pays, provide methods of payment, advise on shipping addresses, list other concomitant medications, and answer additional clinical questions. Based on these responses, the pharmacist may need to provide additional counseling, which further delays the prescription.
After all these processes, the medication is finally ready to leave the building. Prescription fulfillment areas work to package medications in appropriate shipping containers (ie cold chain) and load the medications on trucks for delivery. Fulfillment centers may periodically get behind on work, due to sheer volume of prescriptions leaving each center, and packages are occasionally lost or erroneously delivered. All of this adds up to additional time for patient delivery.
Refills and follow-up
After a patient receives their medication, follow-ups and other patient engagement tactics are employed. As opposed to retail, due to contractual agreements, specialty pharmacies will maintain high contact for certain patient populations to ensure effective treatment and medication adherence.
Although the patient has finally received their prescription, they often do not understand why they now need to spend additional time for clinical or adherence follow-up. For new patients, this whole process can be overwhelming, especially among those who are newly diagnosed.
The process for new patients and new referrals is very similar at many specialty pharmacies. Most specialty pharmacies wish they could do a better job to expedite this process through various workflow designs or company structure (ie therapy-centric pharmacies).
However, as a staff pharmacist fielding daily calls, it is essential to have a grasp on this process to empathize with frustrated patients and prescribers. The next time a doctor’s office is upset that they sent a prescription in days ago with no word from the pharmacy, an exasperated nurse who has been working for weeks with insurance and other pharmacies, or a patient is wondering why they must answer a million questions to get a prescription they used to get at their local pharmacy, you can provide an answer.
Knowledge is power and sometimes an answer and truthful explanation about why it takes so long is all that is necessary to keep everyone happy.
About the Author
Alex Toman attended Duquesne University, earning his Doctor of Pharmacy degree in 2011. Alex worked as a retail Pharmacist until 2015, at which time he transitioned into a clinical Pharmacist role within the specialty pharmacy industry. He 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.