Understanding the Top Challenges of Specialty Pharmacy Services

The journey of the specialty pharmacy patient is a complex and expensive process, as most any hub services participant knows. It starts when the patient is diagnosed with a life-changing chronic or complicated condition and the pharmacy receives the order for a specialty drug. 

Due to the high costs of specialty medications, patients are saddled with hurdles to get to therapy. One example is satisfying insurance requirements for prescription enrollment and payment. Hub services support the patient traversing the many complexities and serve as an intermediary between the physician, patient, payer and drug manufacturer. 

Even with the assistance of these intermediaries, manual processes and minimal standards exist. Hub services companies face their own unique challenges to help physicians and patients effectively navigate the specialty approval and fulfillment process. Here’s a look:

‍Getting a Patient to Initiate Therapy Is Increasingly Difficult 

The United States spent approximately $577 billion on prescription drugs in 2021. Approximately half of this spend ($285 billion) was attributable to specialty medications. Even though less than 2% of the population uses specialty drugs, those prescriptions account for a staggering 51% of total pharmacy spending, according to Evernorth’s 2020 Drug Trend Report.

Specialty medication costs and use are skyrocketing as evidenced by:

• Specialty drugs lead drug spending. Health plan and Pharmacy Benefits Manager experts who manage drug costs spoke at the 2022 Asembia Specialty Pharmacy Summit in Las Vegas, reporting that specialty drugs now account for 50% or greater of the total prescription spending they manage. In some cases, employer clients are seeing specialty costs account for 60% or even greater of their total drug spending.

• Black hole of patient onboarding. The evolving mix of hub service stakeholders ─ provider, health plan, drug manufacturer, dispensing pharmacy and multiple service organizations ─ participate in a complex set of manual touchpoints, transactions and handoffs to address patient enrollment, access and ongoing management of high-cost specialty meds. As manufacturers look to develop increasingly complex drug products, including gene and cell therapies, so too will hubs require a higher degree of specialization and flexibility.

• Outdated enrollment modes. Before patients can fulfill their prescriptions, they must rely on inefficient, manual communication (phone, fax, paper, etc.) for prior authorization. These patients often have polychronic conditions that require multiple specialty drugs, each with a unique, complex enrollment process.

• Shift to lower-cost sites of care. Infused therapies make up approximately one-third of specialty medications. Traditionally administered in outpatient facilities or physician offices, they are now moving to lower-cost sites of care, for example, the patient’s home, adding to the logistical complexity.

• Greater need for patient resources. Specialty drugs involve complex treatment regimens that require pharmacists and personnel to provide ongoing clinical monitoring and considerable patient education to promote adherence beyond traditional dispensing activities. Multiple languages and education methods must be accessible to patients to ensure proper drug use. Treatment of diseases or conditions can be marked by long-term or severe symptoms or high drug interactions that need proactive monitoring and management.

• High worker turnover. Pharmacy leaders face a staffing crisis with contact centers seeing double-digit turnover and a severe lack of candidates to fill open positions.
  

Impact of Top Challenges of Specialty Medications

These barriers result in significantly higher risks of complications, negative impacts on clinical outcomes, and even mortality.

1. Late patient engagement. Specialty drugs are vastly more expensive than their traditional drug counterparts, often costing more than $2,000 per month per patient. Patient engagement occurs too late in the fulfillment process where the inability for the patient to pay may become a barrier to treatment.

2. High prescription drug costs. Prescription abandonment rates are less than 5% when the prescription carries no out-of-pocket cost; it rises to 45% when the price is over $125 and to 60% when the price is more than $500.

3. High rates of non-adherence. High rates of non-adherence are believed to result in $300 billion of avoidable healthcare costs. As an example, three out of every four hospital admissions in oncology are due to non-compliance with the patient’s drug therapy.

Why We Must Accelerate Time to Therapy 

Once you understand the factors contributing to slowdowns in the process ─ causing people to abandon their specialty prescriptions ─ you can create an efficient and effective tech-driven patient access strategy to accelerate time to therapy. 

In the next blog, we will explore a variety of use cases applying artificial intelligence (AI) to modernize the specialty pharmacy hub’s multi-layer communication processes that touch hundreds to thousands of participants daily. We will also review key linkage points in the patient’s journey to digitally automate to provide care faster anytime and anywhere. Specialty healthcare teams supporting the sickest patients must be equipped with the right tools to help them do their jobs.