Remapping the Specialty Medication Journey

• Q: Specialty prescriptions are more complex than non-specialty. How does a regular prescription drug move through the prescribing and fulfillment process versus a specialty drug?

  A:

  Byers: Traditionally, the patient visits their doctor and receives a diagnosis, such as hypertension. A prescription is sent to the local pharmacy where a claim is adjudicated. The pharmacist reviews the prescription for safety concerns and dispenses the medication. The whole process could take an hour or two. In many cases, that patient can start their medication the same day.

  On the other hand, let’s say a patient receives a Hepatitis C diagnosis. Not only is that a life-changing moment, but the process is vastly more difficult. The prescription to cure Hepatitis C requires fulfillment by a specialty pharmacy, which is not the same as a neighborhood pharmacy. The specialty pharmacy needs more information, such as data from labs to understand which type of the disease is present, if there are liver complications or the status of other diseases. All of this information is used by the specialty pharmacist in review of the medication order to ensure its appropriateness for the patient. In addition, high cost and benefit plan designs mean prior authorization is almost always required, and this clinical information is necessary to complete it.

  Mellin: And that brings us to the issue of cost. Specialty drugs can cost tens or even hundreds of thousands of dollars a year, and patients’ out-of-pocket costs can be in the thousands. Now, the patient is in shock over both the diagnosis and the price tag. There are assistance programs, shipping and handling considerations patient education, and monthly follow-ups from the pharmacy to ensure adherence and report any side effects. Most importantly, even a single breakdown in this complicated process of gathering information to ensure patient safety, medication affordability and insurance approval adds wait time for a patient who is already in distress.

• Q: Where is the greatest opportunity to improve the specialty prescribing and fulfillment process: people, technology, process or a combination?

  A:

  Mellin: These are miracle drugs and patients are receiving them. But in my more than 20 years in health IT, this is the most complicated process I’ve ever seen to get a patient on a therapy. There are so many stakeholders, handoffs and forms where manual work compensates for the lack of digitization and automation. There is no shortage of opportunities to streamline the processes and eliminate phone calls, faxes and other manual communications—all to track down clinical information and determine which step of the process the medication is on until it’s finally dispensed. Digitizing these processes will allow physicians, nurses and pharmacists to focus on the more valuable parts of the process, like patient care, education and support.

  Byers: From the standpoint of my past role managing a local specialty pharmacy in Minneapolis, I would have said process and people, simply because of the many manual processes involved. There were redundancies and inefficiencies, from accepting the prescription—which arrived by fax more than half the time—to the endless phone calls to providers, insurance companies, patient assistance foundations, other pharmacies and patients. But at Surescripts, I saw new and emerging technology for automating clinical information-gathering, reducing outbound calls to providers and speeding time to therapy. 
  
  Today, we can directly submit prior authorizations to insurance companies to relieve the burden on provider offices. And there are enhanced eligibility solutions that put pharmacy benefit information at your fingertips. So, the opportunity starts with a process and understanding how technology can streamline the work appropriately. But technology and electronic tools cannot fix the problem. It’s also a huge undertaking in change management that requires people to think and behave differently. It’s understanding the value of the technology, and then implementing and utilizing it to see the full value sooner. 

“As an industry, we can’t keep adding more people to manage phone calls and paperwork—essentially adding cost, but not value.”

Andrew Mellin, MD

VP, Chief Medical Information Officer, Surescripts

• Q: Given the influx of FDA approvals and drugs in development, what challenges will prescribers and specialty pharmacies face if we don’t match the demand with an efficient prescribing and fulfillment process? How will these problems manifest for the various stakeholders?

  A:

  Mellin: The current model is unsustainable. As an industry, we can’t keep adding more people to manage phone calls and paperwork—essentially adding cost, but not value. But these are problems we can solve today with advances in interoperability that remove the information “asymmetries” between the physician, pharmacy and payer in the specialty medication prescribing processes.

  Byers: Much of the growth in the specialty market is driven by existing disease states being treated in new ways, like injectable medications instead of oral tablets for migraines and Alzheimer’s. The prescriber must think differently about these specialty medications, and it’s a whole new patient interaction with specialty pharmacies and hubs. We need to provide meaningful patient support as they add a specialty pharmacy to their care team. If we don’t, their experience will feel disruptive and disjointed from their local or regular pharmacy.

• Q: What’s the solution? What steps can the industry take to ensure access to critical data, seamless communication and optimized workflows? And how will this benefit electronic health records (EHRs), pharmacy tech vendors, specialty pharmacies—and ultimately, patients?

  A:

  Byers: Learning about how we’re transforming the specialty medication process is a great first step. Solutions like Specialty Patient Enrollment, Specialty Medications Gateway and Electronic Prior Authorization are all available today and have risen from two decades of network-building expertise to mobilize all sides of the healthcare market. EHRs will benefit from our proven ability to successfully integrate with their technology, and can enable their customers to speed time to therapy—effectively responding to a growing need and setting a new bar for their markets. Pharmacy tech vendors who partner with us to launch new specialty solutions will gain an ally with the scale and experience to truly transform the process for specialty pharmacies—a growing and increasingly influential market. And for specialty pharmacies, we’re revolutionizing the fulfillment process, streamlining operations and improving the turnaround time for patients eager to begin treatment.

  Mellin: The results we’re seeing today from our specialty solutions are nothing short of amazing: eliminating phone calls and speeding time to therapy—all without extra work undertaken by the physician or their staff. And improving the experience for patients, providers and pharmacists doesn’t stop there. Whether through price transparency solutions used during the doctor’s visit to help the patient understand their out-of-pocket costs and lower-cost alternatives, to electronic prior authorization that drastically shortens the time for approval, these solutions are fully integrated with EHRs and pharmacy systems and can transform the specialty medication experience. As I look to the future, the pace of innovation in therapies will only accelerate, prescribing them will only become more complex and physicians and pharmacists will have to reinvent their approaches to ensure the focus remains on helping patients get on the optimal therapy as fast as possible.