While specialty drugs ─ classified as high-cost, high-complexity, or high-touch prescription medications ─ are gaining significant traction in the pharmaceutical industry, they can also present significant challenges for prescribers. Specialty drugs often cost $2,000 or more per patient per month, triggering requirements for prior authorization and potentially step therapy by insurers. Additionally, they may require special handling through injections or infusions, and medical oversight may be necessary to administer them.
Demand continues to grow exponentially, with spending on generic versions of specialty drugs alone representing the largest segments of the healthcare industry, valued at $73.8 billion. The U.S. spent approximately $577 billion in prescription drug expenditures in 2021, with approximately half or $285 billion attributable to specialty medications including generic versions.
Challenges that Keep Specialty Drug Prices High
Healthcare providers struggle to meet complex approval requirements which vary by insurer and medication. While the desire to control costs is understandable, the experience of procuring specialty medications is often manual, bureaucratic, slow and maddening for the prescriber and patient, including requirements for:
- Prior authorization (PA). Approximately 83% of prescribers reported an increase in PA requirements over the last five years. Heavy clinical requirements, competition around less expensive biosimilars, and clinical documentation requirements lead to a lengthy and often challenging approval process for providers and patients alike.
- Step therapy. Try an older, cheaper medication first before “stepping” up to a pricier med is a PA protocol touted by insurers as a way to control runaway prescription drug costs and help patients find the most appropriate treatments. But critics say it can delay symptom relief and allow medical conditions to worsen irreversibly.
- Shift to mail order. Mail-order medications are often less expensive and operate through a patient's health plan. But patients can wait weeks to secure life-improving medication. Once approved, patients will then likely need to use the pharmacy benefit manager’s mail-order pharmacy to obtain their prescriptions, further delaying the arrival of medication and initiation or continuance of treatment.
- Administration outside of the hospital. Hospitals charge higher costs for specialty drugs and their administration than independent practices. The shift to alternate settings requires more coordination to administer specialty drugs in practices and patients' homes.
Hub services assist patients to obtain specialty drugs. They act to traverse the many complex requirements and manual processes and serve as an intermediary between the physician, patient, payer, and drug manufacturer. However, hubs also present unique concerns due to manual processes and virtually no standards-based infrastructure.
Without a clear roadmap to success, hub service companies are challenged to help physicians and patients effectively navigate the specialty approval and fulfillment process.
Healthcare personnel (HCP) staffing shortages also have led to backlogs in gathering and submitting necessary PA requirements for both medical and pharmacy benefits, putting additional pressure on already stressed medical office teams.
Digital solutions reduce HCP burden and speed time to therapy
The rise of specialty medications demands digital innovation. Pharma manufacturers, including hub services, are automating key points along the patient journey with healthcare chatbots, virtual visits, and two-way HIPAA-compliant secure messaging.
The emerging reliance on artificial intelligence (AI) equips hubs with new capabilities to drive down costs. Organizations that are accessing digital services are:
- Speeding time to therapy
- Increasing staff efficiencies
- Accelerating throughput by boosting prescriber and patient engagement
- Streamlining the multi-layered communication across patients, HCPs, insurers, and hub service participants
What can forward-looking hubs do to quickly ramp up? To follow is a short list of where AI can help:
Initiate patient engagement early
- Speed entry into patient assistance programs. Use digital outreach to obtain consent and provide program information.
- Capture missing patient consent. This helps close gaps in missing documentation.
- Update insurance information. Enable patients to scan their current health plan card.
- Distribute branded welcome packets. Automatically provide digital content.
- Offer guided assistance to relevant patient education materials. Provide multimedia options to reinforce a patient’s understanding and self-care.
- Deliver branded coupons or copay offers. Supplement with accessible digital material.
- Enroll in therapy support programs. Provide information about relevant support groups.
- Leverage virtual visits. This two-way or three-way communication provides a personal touch to quickly resolve issues. Patients can initiate secure messages to address questions, concerns, or payer requests for information.
Reduce provider burden
- Capture missing physician signatures. Skip faxes and multiple phone calls by forwarding the digital form, enabling the HCP to sign and upload it to hub system technology.
- Send physician education materials to high-volume specialty physicians.
- Automate payer authorization requests for additional information.
- Replace phone tag with secure two-way messaging. This enables asynchronous coordination between the HCP, the hub service provider and the patient. Create Quick Messages to expedite common responses.
Speed up the prior authorization process
- Close gaps in documentation with physicians or patients or both.
- Enable patients to self-schedule urgent concerns to live agents.
- Securely transmit images and documents or scan insurance cards between the HCP office and hub service participant, and capture patient signatures.
The shift is underway. Now is the time to embrace digital. Digital hubs that deliver the “right messages to the right patients at the right time” not only speed access to life-saving therapies, they can also make sure meds are taken as prescribed for the duration of the treatment plan.
We invite you to see for yourself an example of how healthcare chatbots can streamline onboarding.
Ready to learn how QliqSOFT can help automate your pharmacy hub services? Contact us today to discuss your challenges and allow us to craft a personalized solution for you.
Krishna Kurapati is the Founder and CEO of QliqSOFT. He has more than two decades of technology entrepreneurship experience. Kurapati started QliqSOFT with the strong desire to solve clinical collaboration and workflow challenges using artificial intelligence (AI)-powered digital technologies across the U.S. healthcare system.
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