HIT Perspectives: Five Trends Leading the Digital Transformation of Specialty Pharmacy

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HIT Perspectives – June 2019


Five Trends Leading the Digital Transformation of Specialty Pharmacy

Pooja Babbrah


By Pooja Babbrah, PBM Practice Lead


DNASpecialty medications are changing health care, providing life-saving treatment options for patients with rare and chronic conditions. Commonly defined as high-cost, high-touch drugs, they often have special handling, dispensing, oversight and delivery requirements. In the past, much of that was handled through retail specialty pharmacies. However, the roles of specialty pharmacies and others involved in the fulfillment process are changing with the increased use and costs of specialty medications, the evolving health care landscape and new technologies emerging to automate specialty pharmacy, streamline operations and improve speed to therapy.

So, what trends are influencing the specialty pharmacy of the future? Here are five to watch.

  1. Value-based arrangements target costs and quality. Value-based delivery models, which reward providers for better managing costs, quality and health outcomes, have been springing up over the past few years. Similarly, value-based frameworks and payment models are expected to expand to the specialty arena and, potentially, whole classes of drugs. For example, Novartis negotiated pay-for-performance agreements with insurers Aetna and Cigna for Entresto (sacubitril/valsartan), which is used to treat heart failure with reduced ejection fraction. Cigna will adjust payments according to patient hospitalization rates, while Aetna’s payments will depend on whether real-world results are on track with those seen in clinical trials. This trend will require both manufacturers and payers to develop evidenced-based quality and outcomes measures, as well as new ways to report them.
  2. Increased vertical integration will impact fulfillment. Expect to see the impact of vertical integration of pharmacy benefit managers (PBMs), specialty pharmacies and insurers. For example, Cigna recently joined forces with the PBM ExpressScripts, which had previously acquired specialty pharmacy Accredo. Why are payers interested in partnering with PBMs and specialty pharmacies? Those that have their own PBMs and specialty pharmacies see better access to health care and utilization data in real, or nearly real, time. This provides valuable information and insights that can lead to strategies for cutting costs and improving quality. It is difficult to manage costs of care without managing prescription spending, especially for expensive specialty medications. In addition, specialty prescription drug spending is rising as these drugs become more expensive. As a result, adding specialty pharmacy to the mix gives payers expanded capabilities to better manage costs for drugs covered under patients’ pharmacy and medical benefits. Vertical integration also allows for increased controls for benefit management, including formulary exclusions, site of care management and increased utilization management.
  3. Integrated delivery networks will include specialty pharmacies. Physicians and hospitals are increasingly merging to form integrated delivery networks (IDNs) as a way to reduce costs and improve outcomes, and are now beginning to include specialty pharmacies. By establishing their own specialty pharmacies internally, IDNs can leverage better control over drug selection and prescribing, patient care and outcomes. This results in better cost oversight and access to specialty pharmacy data, which can help providers target ways to improve quality of care and outcomes. Additionally, specialty pharmacies are often adjacent to the facilities where their patients receive care. This creates opportunities for face-to-face engagement with patients and providers, potentially improving adherence and satisfaction. This arrangement also provides more integrated care for complex, chronic conditions, which can close the gaps in care created when specialty pharmacies are not directly part of the care continuum.
  4. Emergence of new therapies will impact business models. Expensive new specialty medications are coming to the marketplace. According to one estimate, 225 specialty-type medications will be available by 2025 — and they are likely to be expensive. For example, the Food and Drug Administration has recently approved a second gene treatment for infants with a rare condition called spinal muscular atrophy that has a price tag of $2.5 million per dose.These types of therapies will be gamechangers. Gene therapies are primarily handled in hospitals, in contrast to the usual sites of dispensing and administration for specialty medications that include physician offices, clinics and retail specialty pharmacies. This will impact the business models of payers and clinicians alike. For example, they will have to develop new cost and reimbursement structures, new types of clinical management and logistical support, and new patient education and follow-up mechanisms.
  5. New technologies will address patient, provider and payer pain points. Specialty pharmacy is coming into the digital world with continued emphasis on computerizing its manual phone-and-fax processes. A key example is the National Council on Prescription Drug Programs’ new Specialty Work Group working to identify pain points and transactions that delay the prescribing, enrollment, dispensing, care management, reporting and payment of specialty medications. These efforts build on electronic prescribing standards as well as complement the work under way to automate other aspects of specialty pharmacy.

Want to know more? Visit our presentation library for recent presentations focused on the trends described here or reach out to me at pooja.babbrah@pocp.com.