Specialty pharmacy stakeholders must strike a delicate balance between cost concerns and health outcomes, while keeping the patient at the center.
Imagine that after years of experiencing an overall unwell feeling and sometimes debilitating symptoms, as well as months of doctor visits, referrals, lab draws, and additional tests such as endoscopies and colonoscopies, you finally have a follow-up visit with your gastroenterologist. Based on the information collected over the past few months, the physician advises you that you indeed have a diagnosis of Crohn disease.
Several thoughts, emotions, and questions flood your mind all at once. You feel uncertain, anxious, and perhaps even fearful of what is next. You may question what it all means, what is Crohn disease, how it will affect your immediate and long-term life, and where you go from here. These are all questions that certainly popped into my friend’s mind when he was diagnosed with Crohn disease 5 years ago.
Post-diagnosis, my friend was prescribed methotrexate to manage his condition. As his journey began with this new diagnosis, he described this experience as taking on another full-time job.
Reason being, he felt that in order for him to manage his disease appropriately, he needed to be heavily invested in his heath and follow his physician’s orders, starting with all of the requested office visits and necessary blood work required to appropriately manage his disease. Over time, he began to experience flare-ups and reverted back to completing additional tests to see whether he was a candidate for a biologic agent, which can have several adverse effects and may be relatively expensive but could provide relief and help him function on a daily basis.
The evaluation for the viability of a biologic agent included testing for everything from tuberculosis to electrolyte values and complete blood counts, as well as swallowing a camera and wear a pack all day while pictures were taken of the colon and small bowel that could be shared with the care team.
Luckily, my friend did not need any procedures to remove ulcerations, but it was determined that he was a candidate for a biologic agent and was started on a TNF-inhibitor shortly thereafter. Once it was determined which biologic he would be started on, he was provided with injection training and learned all about the various sites where he could administer the medication.
He was also taught about how frequently his medication should be administered and how it should be stored and prepared prior to administration. He quickly found out about the high cost of these medications but thankfully he is doing well on his regimen and continues to see his physician twice per year to ensure appropriate management of Crohn disease. He left me with this thought after our discussion, “this is a life-long battle and one that has changed my life.”
As I listened to his story, it made me think about all of the stakeholders involved in the specialty process and what the ideal process might look like to the patient despite the numerous players involved. With the emergence of specialty and the high focus on the ability to drive positive health outcomes and manage costs, this presents an opportunity for specialty pharmacies to consider the services they offer to patients and other stakeholders in the business to create the ideal process for everyone.
After all, if beauty lies in the eyes of the beholder, shouldn’t we be thinking about this process from the patient perspective and understanding what best fits their needs while still achieving positive clinical outcomes and management of costs? With that being said, let’s take a step back and think about the patient journey after diagnosis and the stakeholders involved, including the provider and payer.
Specialty Stakeholders and the Specialty Pharmacy’s Role
Let’s refer back to my friend from above. After years of feeling unwell and many tests to confirm his diagnosis of Crohn disease, he is now faced with the reality that his existing medication regimen is not working and he may need to try a biological agent due to progressive disease.
Once he has approved to try a biological agent, he is handed a prescription and off he goes to his local retail pharmacy. Little does he know that many times, biological agents are dispensed via a specialty pharmacy. This may be because of a patient’s benefit design or because the medication is part of a limited distribution network and only available through certain pharmacies.
Whatever the reason, although some pharmacy benefit managers have helped to expedite the filling of a specialty medication despite being dropped off at a retail location, others may simply advise the patient to call a phone number in order to fill their prescription, leaving some patients confused. This may be a bit dramatic with the growing use of ePrescribing, but even if the script were automatically faxed to the specialty pharmacy, I imagine it may be a bit mind-boggling to have someone reach out over the phone to verify, counsel, and ultimately fill a potentially life-saving or life-sustaining medication without ever meeting them.
It is very different than any experience a newly diagnosed specialty patient would have likely had in the past, in which they would go to a pharmacy, pick up their prescription, and ask the pharmacist any questions they may have about their medication. Herein lies one of the biggest opportunities for specialty pharmacies from the patient’s perspective—to truly build a trusting relationship with the patient, especially since they cannot see their pharmacist face-to-face as they do in a retail setting.
Typically, core information relayed to specialty patients includes items such as coverage and financial support, adverse effect management, and adherence counseling, but what if much more was involved especially upon the initial fill? For example, an introductory call from the pharmacy could explain why a patient’s medication must be filled through this channel, what the patient can expect throughout treatment, patient education, clinical monitoring and adherence counseling, and additional services the specialty pharmacy can assist with. These services include financial assistance, physician collaboration, 24/7 support, and flexibility as to how, when, and where a medication can be delivered.
It would also be beneficial to offer face-to-face interaction via video chat or FaceTime to help patients feel more comfortable and confident regarding how and by whom their prescription is being handled. Directing the patient to a video or testimonial may also be helpful in building both comfort and confidence between the patient and pharmacy.
This isn’t to say that specialty pharmacies are not currently performing some, or many, of these tasks. It is merely to point out the huge opportunity that exists when a patient is new to a specialty pharmacy and how crucial it is to make a good first impression.
It is important to remember that specialty disease states do not affect a specific patient population. In other words, although a physician may be dealing with a smaller overall patient population, all of these patients likely have different benefits. For example, a formulary drug for a patient may not be covered for another patient.
There could also be differences in buy-and-bill requirements, copayments, or access restrictions across various patient’s plans. From a provider’s perspective, I imagine it would be helpful to have partners in the specialty pharmacy space that could help the physician navigate this information easily and provide updates on which medications it has access to, as this can change.
Going back to the patient’s perspective, this insight and partnership between providers and specialty pharmacies would also help to expedite getting a patient started on therapy. It may also be helpful for physicians to have access to important information regarding their patients, such as prescription status, compliance information, and any reported adverse effects or additional conditions that could affect their current specialty state, allowing for continuity of care across all health care professionals and stakeholders involved.
It may even be helpful for physicians and pharmacies to establish rounds to discuss patients that may be at particularly high risk to unify the care team and establish proactive care plans to avoid medical complications.
Finally, most specialty prescriptions require prior authorization (PA) review prior to dispense. This is to ensure appropriate use of these high-cost, complex medications, but can place additional administrative work on physician and their staff to complete. Another opportunity within the specialty model is to have specialty pharmacies assist with the completion of PA forms based on information they may have collected through the benefits verification process and one that would again expedite the time it takes for patients to receive their medication.
Payers are faced with the challenge of building a benefits package that not only ensures appropriate access to medications and maintains satisfaction with its members, but also that balances the costs associated with the plan. Therefore, the best partnership between a payer and a specialty pharmacy would be highly focused on outcomes and has the ability to track and report on measures such as prior approval rates, time taken to fill a prescription, adherence measures, additional medical costs, member outreaches, and drop-offs in therapy so that the payer can act where and when needed.
Specialty pharmacies providing this level of detail to payers not only helps them better understand their return on investment in specialty drugs, but also provides a closed loop and consistent approach to care in the best interest of the patient.
Although we certainly need to balance cost concerns with health outcomes and we may not be able to employ all of the techniques mentioned above, we must remind ourselves that many of these therapies can be life-changing. As such, we should continue to build processes that not only continue to engage all of the stakeholders but put the patient first. After all, beauty lies in the eyes of the beholder.
About the Author
Lauren Meyer earned her Doctor of Pharmacy degree from the Duquesne University School of Pharmacy and is currently enrolled in the Master 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. She has spent the past several years working as a clinical advisor assisting employers with their pharmacy benefit management strategy. Prior to this experience, she completed a PGY-1 managed care residency.