Breaking Down Silos in Specialty Medication Prescribing and Fulfillment

The paper map analogy is an apt one, but the process could also be compared to that old Abbott and Costello radio skit: “Who’ s On First?”, although with decidedly less comedic outcomes. Patients, payers, prescribers, hubs and pharmacies must rely on an inefficient, labyrinth-like system riddled with complex reporting requirements due to these drugs’ costliness, outdated communication technology and a dearth of real-time data to keep the prescriptions moving.

We recently talked to a few of these stakeholders about the challenges and opportunities for improvement. 

The Patient: The Full Time Job of Getting Your Medication

“Patients have to self-advocate,” said Steffany Stern, Associate Vice President of Advocacy and Policy at the National Multiple Sclerosis Society. “They spend hours on the phone, bouncing between their provider's office, their health insurer, their specialty pharmacy, their patient assistance program, et cetera, because those entities are just not set up to talk to each other.”

Stern’s vocation is an inspired one. Her mother has multiple sclerosis, who recently went on an onerous journey to get on a new medication. She needed co-pay assistance, so she reached out to a co-pay fund. The fund said to ask the drug company for help; the drug company asked her to go back to the fund. Then she and Stern’s father engaged with the specialty pharmacy for several days to learn the exact co-pay without getting a consistent answer. They turned to the health plan, who confirmed the co-pay, so they went back to the specialty pharmacy, who then told them they didn’t have the prescription. Finally, Stern’s dad called her mother’s neurologist, but it still took several days to get the prescription, likely due to a prior authorization issue.

“My mother said, ‘I felt like a ping pong ball.’”

It took three months for Stern’s mother to receive the new therapy she’d wanted to switch to for years—and she was off her original therapy for three and a half weeks, which can leave such patients vulnerable to relapse.

“If I had to describe a more perfect process, it would be streamlined,” she said. “We need to clarify it as much as possible because patients often find it impossible to even identify what the hang up is.”

Shared decision making between provider and patient in picking the medication should be the standard, Stern added. The patient needs to fully understand the utilization management requirements and out-of-pocket costs at every point. Technology that allows all the players to communicate seamlessly is key to creating needed transparency. And she hopes that partners keep the patient experience in mind when designing this technology, Stern said. “For these people, simply getting their disease modifying treatments can really feel like a full-time job.”

Life Sciences: 43 Days to Get a Patient Started on a Drug is 40 Days Too Many

Brian Bamberger, a 25-year veteran of the pharmaceutical industry, says he’s never been more excited at the prospect of health technology and new pharmaceutical treatments.

“These exciting treatments bring new challenges, and many of those challenges revolve around communicating the best information to providers and patients when they need it,” said Bamberger, Life Sciences Practice Lead at Point-of-Care Partners, a consulting firm that works with stakeholders in the specialty space. “Technology has made major gains over the last decade, but there are still gaps.”

Bamberger described several of these gaps, beginning with coverage information. For example, does this therapy fall under the medical benefit or a pharmacy benefit? The second gap lies between the specialty pharmacy and distribution channel.

“There's a logical limit to the number of places that it makes sense to inventory an expensive specialty medication. Each payer has its own pharmacy and distribution organizations it favors, and manufacturers may have limited distribution as well, because of the logistics involved,” said Bamberger. “Health systems, too, want to play a role in distribution, because 43 days to get a patient started on therapy is 40 days too many.”

The next challenge is keeping patients and providers continually updated throughout the process to set expectations on timelines and treatments.

Finally, he said, the prior authorization process needs an overhaul, and he thinks standardizing question sets and automating the exchange of information is critical.

“All of these challenges are complex…but we believe these challenges can be overcome with the involvement of the entire healthcare community,” said Bamberger. “Technology has a role to play, especially in communicating information that is complete and trusted and secure.”

Specialty Pharmacy: The Days of 50-Page Faxes Need to Go Away

Like Bamberger and Stern, Joel Helle, Vice President of Physician Services at CVS Specialty, believes digital innovation provides opportunities to vastly improve the specialty space.

“We need to work cross-functionally across all the different stakeholders to look for opportunities for closer communication, and to support the patient in getting and staying on their medications,” said Helle, who’s been working in specialty for 11 years, and calls it a “fragmented landscape”. 

When providers leverage electronic prescribing, it clearly enhances the patient on-boarding process, but it’s just a start. At CVS Specialty, when the pharmacy team receives the prescription, they can also access the patient’s electronic health record to pull any additional information the payer may need to approve a prior authorization, said Helle, significantly speeding up any delays due to missing data. He also finds the increase in interoperable platforms promising so that “when a doctor, a pharmacy or a hospital needs [patient] information, it’s more immediately available” and, happily, fax-free.

Helle is also proud of the work CVS Specialty has done to make secure messaging available between patients and pharmacists via their CVS Specialty app. “A patient can type into the app, ‘I'm experiencing this,’ and a pharmacist can come back and say, 'This is what that means.’ This [secure messaging] has really changed our specialty pharmacy in a great way, because patients can get the information they need,” said Helle, whether to learn more about their prescription status or refills, potential delays, or discuss symptoms and outcomes.

Clearly, streamlined and automated processes can transform the specialty medication system, give time back to care providers and get patients on their therapies more quickly. As Stern, Bamberger and Helle shared, this transformation requires collaboration and communication across all stakeholders, and their organizations are all working to that end.

At Surescripts, we’re committed to convening and engaging the best and brightest—as well as their diverse perspectives and challenges—to remap the specialty medication journey and disrupt outdated models. Our proven technologies and two decades of network-building expertise equip us to mobilize all sides of the healthcare market around solutions that improve the specialty medication process.