Specialty medications, already the fastest growing segment of total pharmaceutical expenditures, are poised to consume an
increasing percentage of healthcare dollars. Specialty pharmaceutical sales prices are growing at nearly double the rate as
general pharmaceutical sales—about 20%, year over year. With hundreds of new specialty drugs in the pipeline, including almost
200 drugs in Phase II and Phase III clinical development, the upward trend will probably continue for the foreseeable future.
Specialty drugs are generally expensive ($8,000 to $300,000 per-patient-per-year) and are used to treat a small population
of patients with chronic, potentially life-threatening diseases. Most require injection or infusion, as well as refrigeration
and special handling.
Rising utilization will also impact how much managed care organizations will pay for specialty pharmacy benefits in the future.
While only 2% to 3% of a typical health plan population currently requires specialty medications, those members are responsible
for at least 25% of a health plan's costs and eventually could account for up to 50%. Currently, conditions most commonly
treated by specialty pharmaceuticals include: anemia, cancer, growth hormone deficiency, hepatitis C, immune deficiency, rheumatoid
arthritis and multiple sclerosis. But utilization will soar as new specialty drugs in the pipeline to treat cancer, autoimmune
conditions, infectious disease and HIV/AIDS are approved.
Managing specialty drug programsThe high cost and complexity of specialty drug regimens, fragmented coverage split between medical and pharmacy benefits categories,
and the need to ensure that patients receive the right drug, in the right dose, at the right time, present significant challenges.
MCOs must implement innovative, comprehensive, integrated programs to balance effective cost management and member care. Otherwise,
soaring costs and employer dissatisfaction will erode their bottom lines.
Establishing and managing evidence-based specialty pharmacy programs that provide the right balance between cost control and
patient care can be daunting. For many MCOs, partnering with an organization with a proven track record in delivering best
practices in specialty pharmacy program implementation and coordination is often the best approach. However, since no two
payer organizations are alike, it is vital to select a partner with the expertise and resources to fully assess an MCO's needs
and challenges, as well as to develop a customized program that addresses specific requirements.
To ensure the success of a specialty pharmacy program, MCOs should select a partner that can offer comprehensive cost containment
services, clinical services designed to improve outcomes and maximize member care, sophisticated data analytics and reporting,
as well as accountability.
Capabilities should include:
Cost Containment
- Competitive pricing with cost model options that include average wholesale price (AWP), wholesale acquisition cost (WAC) or average sales price (ASP) pricing models.
- Utilization management on all dispensed medications to avoid waste, compliance problems and inappropriate prescribing. A comprehensive patient education
and safety assessment should be completed before any medications are shipped to ensure the patient is prepared to start therapy
and medication will be used appropriately.
- Formulary management and therapeutic interchange that enables manufacturer program support through rebates and/or educational grants to support patient education and compliance.
- Maximum utilization and savings through effective program implementation that incorporates best practices in specialty pharmacy program implementation.
Clinical Services
- Patient education, counseling, compliance monitoring and intervention to ensure patients understand their therapy, to track compliance and to intervene when problems are identified. Services
should be available for all specialty patients, whether they receive direct shipment of medications or they are treated at
a physician's office.
- Disease-specific Medication Therapy Management (MTM) programs to serve the special needs of high-risk populations with chronic and complex diseases that ongoing require drug therapy and
adherence monitoring.
- 24/7 clinical patient counseling by registered pharmacists and nurses to assist patients who experience difficulty administering their medication, unanticipated
side effects or other problems that need immediate professional attention.
- Prior authorization services that include criteria development, process development, administration of criteria and step therapy, approvals and communication
of approvals to the prescribing physician.
- New product and category review services to provide pipeline information and clinical resources to facilitate formulary and medication management planning.
Data Analytics and Reporting
- Proprietary systems that capture and integrate pharmacy and medical data to provide a complete understanding of specialty spending.
- Financial and clinical reporting that generates current spending and utilization data to support financial projections and budget planning. Includes comprehensive
business reviews that evaluate program results and goals, which are essential for evidence-based decision-making.
Based on current trends, specialty medications will likely remain the fastest growing segment of the prescription drug spend
for years to come. MCOs that don't implement an effective specialty pharmacy management program now run the risk of serious
bottom-line erosion in the near future. However, establishing a cookie-cutter program that doesn't meet an MCO's specific
needs can also hurt their bottom line. One solution is for MCOs to align with an organization that has the experience, resources
and proven track record to help them develop and implement an effective, flexible, targeted specialty pharmacy program that
delivers cost savings and quality care for patients and families.
Kerr Holbrook is the vice president of marketing for McKesson Specialty, which provides comprehensive specialty pharmacy solutions
for payer organizations to expand access, reduce costs, and improve outcomes for treatment of patients with chronic and complex
conditions.
