Navigating Patients through Specialty Pharmacy

One day a woman dropped off a prescription at her local pharmacy for her husband’s rheumatology medication.  Neither her nor her husband are medical professionals.  She was shocked to learn that the medication was going to cost $6,000 and their insurance was not going to cover it. She called to convey how upset she was.  How were they going to afford this medication?  The couple came to the difficult decision that they would need to either find a cheaper alternative or he would have to go without the medication that he desperately needed.

This is a common scenario when specialty medications are prescribed. Patients are often unaware that they need to be filled at appropriate specialty pharmacies.

More than half (51.8%) of adults in the United States have at least one of ten diagnosed chronic conditions (arthritis, cancer, chronic obstructive pulmonary disease, coronary heart disease, asthma, diabetes, hepatitis, hypertension, stroke, and weak or failing kidneys) and 27.2% of US adults have multiple chronic conditions. The top disease states that require specialty medication treatments include, but are not limited to, cancer, Cystic Fibrosis, Hemophilia, Hepatitis C, HIV/AIDS, immune disorders, infertility, Inflammatory Bowel Disease (Crohn’s Disease & Ulcerative Colitis), Multiple Sclerosis, Psoriasis, Pulmonary Hypertension and Rheumatoid arthritis. 

These specialty medications can be cost-prohibitive with the average price being ~$85,000 per medication per year.  Retail prices for widely used specialty medications increased at more than three times the rate of general inflation in 2020. The average American cannot afford these medications without the help of insurance, co-pay assistance programs from the manufacturers and additional help from various funding organizations that specifically offer aid to chronic disease patients. 

In addition to high costs, the process to fill and dispense these medications is disjointed.  Often, prescribers are unfamiliar with the specialty pharmacies that can dispense these types of medications. This can lead to prescriptions being sent to pharmacies that do not have the resources to fill them and therefore never reach the patients.  Two out of three healthcare providers said they change or reroute their orders when they encounter barriers to specialty prescribing, sometimes resulting in lost prescriptions.  Non-adherence of these specialty medications leads to preventable hospitalizations and deaths costing roughly $500 billion of the entire US healthcare spend every year.

For prescriptions that do reach the appropriate dispensing pharmacies, there can be additional challenges that further delay treatment initiation.  Outdated technology (lack of electronic medical records and e-prescribing capabilities) between the provider and pharmacy, manual processes involving benefits investigation and financial assistance, prior authorization management, and incorrect patient information are just a few examples of what can further postpone medication delivery.  69% of specialty pharmacists said that pharmacy administrative tasks restrict providing patient care in a timely manner. Furthermore, there may be difficulty engaging and communicating with patients (language barriers, technology issues, etc.) as well. 

Once the patient has navigated through all this red tape to finally receive their medication, non-compliance can be another barrier if patient education is lacking.  Combined with adverse events or side effects that patients don’t know how to manage, this can lead to further non-adherence and premature ending of the medication regimen. 

There is also a correlation between prescription abandonment and medication costs. According to a 2020 report by the IQVIA Institute for Human Data Science, prescription abandonment rates are less than 5% when there is no expense to the patient. However, once the cost is more than $125, the prescription abandonment rates rise to 45% and then to 60% when costs rise above $500. To put this in perspective, 55 million new therapy prescriptions were abandoned at pharmacies in 2020.

When speaking to patients about what matters the most to them in taking their specialty medications, they list the following in order of importance:  

  1. Information about their chronic condition
  2. Management of side effects
  3. Understanding the background of insurance to get prescriptions covered
  4. Appropriate training on how to use/administer medication
  5. Assistance with filling out documentation for financial assistance
  6. Availability of nursing or clinical support 24 hours per day
  7. Social resources (transportation, support, etc.)

Improving this convoluted process will help initiate patient treatment sooner and bring better results for the patient and their entire care team.  Simplifying the communication between prescribers, patients, pharmacies, insurance companies, and manufacturers can assist to lower overall healthcare costs, decrease time to therapy initiation, improve adherence rates, reduce readmission rates, enhance the education of patients, and improve overall patient outcomes. Better technology, communication processes, and education are some of the key answers to help modify and improve workflows and decrease the burdens of everyone included in the care coordination process.  Such enhancements will help to decrease the confusion and misguided steps in the maze of navigating the world of Specialty Pharmacy. 

Interested in learning more about how AssureCare’s solutions are supporting Specialty Pharmacy? Check them out here.

Kelly Malkamaki

Kelly Malkamaki

RPh, Senior Product Pharmacy Analyst