A point well-taken. "We are still on the ground floor of determining specialty pharmacy efficiencies," says Mark Merritt, president and CEO of the Pharmaceutical Care Management Assn. (PCMA), a national group based in Washington, D.C., representing pharmacy benefit managers (PBMs).

"We are searching for the right paradigm, for a consensus method of measuring outcomes," he says. "Right now, we will continue to do what we do best—network, distribution and formulary management, appropriate utilization and prior authorization with an emphasis on managing overall costs. These efforts enable us to quantify added value." Like Vogenberg and Blaylock, he believes that specialty pharmacy bumps up against disease management.

SHARING OUTCOMES: A MIXED BAG

Steve Russek, vice president of clinical product development for Accredo Health Group, admits that the industry can do better, and that there is not yet a focus on outcomes as an end point. As plan pharmacy directors have mentioned, compliance statistics top the list of targeted and most readily available outcomes.

Russek says that different disease states, however, do present opportunities to track results—especially the effect of compliance on quality of life and costs.

"Our focus is drug management of the entire therapy," he says. Accredo, a Memphis, Tenn.-based, wholly owned subsidiary of Medco, follows compliance for hepatitis C medications, whose side effects often deter patients from taking the full therapy and consequently do not suppress the virus.

The specialty pharmacy also measures asthma patients' use of Xolair (omalizumab) and its effect on emergency room visits and hospitalizations, as well as looking at the number of patients on rescue inhalers; ensures that patients on Forteo (teriparatide), an injectable for osteoporosis, do not stay on the drug for more than the two years recommended by the manufacturer, thus reducing patients' chances of bone cancer; and helps to manage hemophiliacs to prevent frequent emergency room visits.

With drug history in hand, Russek says that Accredo also is able to monitor step therapy to ensure that traditional medications are tried first before using specialty drugs.

Difficulty in reporting stems from specialty pharmacy's access only to drug data and not medical information and costs, says Kerr Holbrook, vice president of marketing for McKesson Specialty based in Scottsdale, Ariz. "We have to cooperate with payers to get that information and there are costs associated with that," he says. However, payers are asking specialty pharmacy to quantify value, a combination of quality and costs.

If specialty drugs fall into the pharmacy bucket, says Christine Chow, business manager of specialty pharmacy for Prescription Solutions, a PBM headquartered in Costa Mesa, Calif., it is possible to track compliance and adherence, but when a therapy is covered on the medical side, there is insufficient information to measure drug dose or frequency.

Prescription Solutions focuses its efforts on quality-of-life measures and the effect of prior authorization on drug therapy, or as Chow says, how well patients perform on alternative therapies if authorization is denied. Similar to other companies in its industry, Prescription Solutions tracks compliance on a case-by-case basis and measures outcomes, such as relapses related to MS therapy and length of therapy for those on hepatitis C regimens.

The PBM's Disease Therapy Management program prides itself on helping patients control drug side effects, offers online medication assistance, removes barriers to compliance and suggests lifestyle changes through phone consultations with a care coordinator, similar to a disease management program but more focused on drug therapy.

Despite this personal attention, Chow says it is difficult to access years of pharmacy data for chronic patients—many of whom change health plans before therapy is complete—and the data's effect on emergency visits or hospitalizations.