The use of specialty drugs in the U.S. has skyrocketed in recent years driven primarily by an increase in chronic condition diagnosis and the number of new medications on the market. In fact, it’s estimated specialty medications account for 75% of the approximately 7,000 prescription drugs currently in development, and by 2022, more than 60% of the 600 drugs expected to gain FDA approval will be specialty medications.
There is a seismic shift toward specialized therapies designed to treat very specific, complex conditions. The challenge is, drugs in this category are often difficult to administer and very costly. Specialty pharmacies now have to be ready to not only meet patient demand, but also provide patients the support they need to secure reimbursement, properly administer the drug, and ensure adherence and optimal outcomes.
The problem is, many specialty pharmacies don’t currently have the right tools to support their patients. This is where a tech-driven hub services platform comes into the picture.
Navigating the cost of specialty medications
Though the use of specialty medications has gained a strong foothold in the U.S. and beyond, they still only represent a small fraction of the total prescription drug volume yet account for upwards of 50% of the national drug spend. With specialty drug prices anticipated to rise and the sales projected to grow to as much as $217 billion by 2024, it’s more important than ever for specialty pharmacies to help make these drugs more accessible to patients and demonstrate positive patient outcomes, since that is a key factor in determining reimbursement.
One major barrier to demonstrating positive clinical outcomes, however, is drug adherence. There are a number of factors that contribute to poor adherence rates from a lack of proactive patient outreach and education to a failure to monitor outcomes or provide refill reminders. A primary reason this level of proactive patient engagement has been a challenge for many specialty pharmacies in the past is they haven’t had the technological infrastructure to consistently and efficiently execute on it at scale.
To ensure the number of specialty drugs in the pipeline reach the patients who need them most, and to help ensure positive outcomes, the industry as a whole must undergo a digital transformation.
Using cloud-based technology to manage the complexities
Today, specialty pharmacies are responsible for distributing therapies to the patient on behalf of the manufacturer, so they need a centralized application to support the entire process of patient intake and distribution. As a specialty pharmacy, the number one priority is getting the therapy to the patient as soon as possible so they can begin their treatment. In most cases, the pharmacy is trying to get that therapy, once it’s prescribed, into the hands of the patient within five to seven business days or less. During that time, however, a number of sequences have to occur.
Determining prior authorization and eligibility
Data has to be collected from the prescriber, entered and validated, then the specialty pharmacy has to work with the payer to see what kind of coverage the patient has and if the coverage supports the treatment or not. If it doesn’t, what are the options to get it supported?
If it requires prior authorization (PA), the specialty pharmacy then has to work between the provider and payer to get the therapy covered. This often requires several follow ups. Once it’s covered, the specialty pharmacy then will facilitate getting the therapy to the patient.
It’s imperative this all happens quickly because most patients who require these types of specialty interventions are typically experiencing more advanced health issues. They require more immediate intervention and need to get the therapy as soon as possible.
Processing claims and reimbursements
Another obstacle to adherence is cost. Specialty pharmacies that put processes in place to help ease the financial burden on patients and reduce claim processing time often see improved adherence rates.
Helping patients understand and assess the affordability of specialized therapies, as well as assisting uninsured and underinsured patients gain access to therapies through financial assistance programs, can introduce challenging and time-consuming complexities to the reimbursement process. Cloud-based technology can mitigate much of this process –– confirming eligibility requirements for patients and even finding alternative funding options.
These tools can also navigate billing codes, take over burdensome tasks like benefits investigation and verification, and shorten the adjudication time for claims processing. They can also be configured to provide self-service capabilities to patients, allowing them to locate and apply for financial assistance programs.
Supporting patients over the long term
Still, it doesn’t end once the therapy is delivered to the patient. The specialty pharmacy must then follow up on refills or offer support and education to the patient to ensure they are properly administering and adhering to the therapy.
Most specialty drugs on the market require patients to follow rather complex regimens. They may have to learn how to self-inject medications or be able to recognize side effects, and this can create yet another barrier to adherence. Using cloud-based technologies, specialty pharmacies have a way to provide comprehensive and on-demand support. This could be through automated notifications sent via a text message or app reminding them of dosing times or instructions, prescription monitoring and automated refills, and even patient-accessible portals that house educational modules, training videos, and other forms of support.
All of these touchpoints between multiple stakeholders –– patients, providers and payers –– on top of the increased demand, are increasingly making the case for specialty pharmacies to digitally transform. The tools previously used are no longer enough to navigate and streamline the complexities of specialty drugs.
Making the digital transformation
Specialty pharmacies are no strangers to cloud-based technologies. However, until recently, they’ve primarily relied on very specific software to manage the core business –– prescription processes and management. These tools are still necessary within the specialty pharmacy, however, they were not built to manage and automate the entire patient journey.
Often, specialty pharmacies will attempt to use their existing systems as a “makeshift” hub services platform, but this can create problems because those systems were not designed to manage those complexities at scale. The workaround may suffice for a short time, but if volumes increase, they lose the level of visibility needed to effectively manage patient-specific data such as how many patients are using the drug, if they’re using it properly, what stage of use they are in, etc.
The solution is to integrate existing pharmacy software with a tech-driven hub services solution to manage all aspects of specialty pharmacy –– from back-office and administrative tasks to the patient-facing operations. Outcomes tracking and reporting, along with drug adherence and patient education will be mission critical to making these drugs more accessible to all. The industry must take proactive steps towards leveling the playing field so these important therapies get to the patients who need them most.
Photo: Ridofranz, Getty Images
