December 2016 Vol 9, Special Issue: Payers’ Perspectives In Oncology: AVBCC 2016 Highlights - Specialty Pharmacy
Wayne Kuznar

Washington, DC—Specialty pharmacy has become an extension of the clinical care team in certain medical areas, such as oncology. Integrated service models that leverage the expertise of specialty pharmacies can help optimize patient outcomes, said panel members at the Sixth Annual Conference of the Association for Value-Based Cancer Care.

The oncology landscape is becoming more complex as cancer therapies continue to expand, with 18 cancer drugs approved by the FDA in 2015. In addition, new strategies to manage specialty medications, including aligned or integrated provider networks, shared risk, and bundled payments, are aimed at managing costs, said Matt Farber, Senior Director, Oncology Disease State, Walgreens, Washington, DC.

Spending on specialty drugs has doubled in the past 5 years, and has contributed nearly 70% of the growth in overall drug spending between 2010 and 2015 (Table).

Figure

The fastest growing drug classes in oncology are targeted therapies, specifically monoclonal antibodies and protein kinase inhibitors. The uptake of 2 new drugs, palbociclib (Ibrance) and ibrutinib (Imbruvica), helped drive spending up 27.1% to $9.6 billion in 2015 on protein kinase inhibitors. Many of the recent drug approvals are distributed by specialty pharmacies and have multiple indications.

Payers are struggling to manage the costs associated with these new therapies. “The days of a patient walking in and picking up a prescription are gone. It comes down to a home delivery model and leveraging specialty pharmacy,” said Eric Sredzinski, PharmD, Executive Vice President, Clinical and Quality, Avella Specialty Pharmacy, Orlando, FL. “Manufacturers are making decisions very early about how these drugs are getting distributed,” he added.

Specialty drugs today rarely go directly through the payer without any degree of “lift,” such as a telephone call, or the use of a companion diagnostic or clinical information to support the prescription, said Dr Sredzinski.

Specialty pharmacy is increasingly acting as an extension of the physician’s office, because providers request that the specialty pharmacy review the health plan’s formulary, its prior authorization policies, and the copay structures, as well as plan appeals if coverage is denied, said Dr Sredzinski.

“There needs to be an open collaboration between all stakeholders in the patient’s care,” said Heather Brand, PharmD, Clinical Oncology Pharmacist, Onco360 Oncology Pharmacy, Buffalo, NY. “Obviously, the end goal is to get the patient on the medication with no delay, no gap. Where the specialty pharmacy really comes in is they have the oversight, the expertise, and the knowledge working with multiple insurance carriers. They know what the most stringent requirements are in order to get a prior authorization approved,” she added.

CoverMyMeds is a valuable software tool to automate prior authorizations, saving the pharmacists’ and providers’ time, and helping to speed determinations, said Dr Brand.

Improving Patient Adherence to Treatment

Specialty pharmacies are also involved in reviewing the patient’s ability to pay for specialty drugs, because adherence to treatment is crucial for favorable patient outcomes. Split-fill or limited-­supply programs have expanded to help meet this need. The provider buy-in is necessary to implement these programs, and payers must be able to split the prescription and the copayment, said Dr Sredzinski. Split-fill programs also reduce waste, and save money.

Other adherence protocols emphasize frequent communication with the patient, said Rob Hauser, PharmD, PhD, Senior Vice President, Clinical Analytics, Cancer Treatment Centers of America (CTCA).

“What CTCA does specifically with all of our patients, regardless of whether they’re getting IV [intravenous] chemotherapy or oral chemotherapy, is we have care managers whose full time job is to do nothing but call, follow-up, and stay in contact with the patients,” he said.

The first phone calls to patients typically occur within 12 hours of the patient’s return to home. “When we say we’re helping to fill the prescription, we’re constantly in touch with the patient to find out what their limitations are, what their cost analysis is going to be, and if they can’t afford it, to help them with that,” said Mr Farber. “We also know it’s not just about patient assistance for the drug copay. It’s about assistance for all other costs.”

After receiving a prescription referral, specialty pharmacies conduct a benefits investigation, determine whether providers are in-network, assess copayment exposure, determine the existence of secondary insurance, and work with foundations that provide financial assistance.

Experts in Data Collection

Specialty pharmacy’s ability to gather and report adherence measurements and adverse event data makes it a valuable asset in an era of new payment models in which quality measures are important for reimbursement.

“Specialty pharmacies as a whole have become experts in data collection. [With FDA’s fast-track approval], more and more drugs are coming to market with limited time in clinical trials, with limited data,” said Dr Brand. Specialty pharmacies are uniquely positioned to capture these data.

“To have real world evidence, a lot of manufacturers are leveraging specialty pharmacies to build out that data collection to get the points that they need to prove value in the drugs that they’re bringing to market, and justify the dollars that they’re spending on the drugs,” Dr Brand said.

The acquisition and sharing of data across the oncology spectrum will be fundamental for driving value throughout the system, said Dr Hauser. “The ability to analyze data is going to help begin to drive more value,” he said. “A specialty pharmacy has that ability to capture very unique pieces of data that others in the delivery chain of care don’t necessarily capture, for example, emergency room visits and hospitalizations,” Dr Hauser added.

Specialty pharmacies can also help get the right patients into clinical trials and capture the potential for drug interactions.

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Last modified: December 28, 2016
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