By Tony Schueth, Editor-in-Chief
The use of specialty medications is on the rise especially for the growing number of patients who are chronically ill with such complex diseases as cancer, multiple sclerosis and rheumatoid arthritis. However, these drugs are expensive and complicated to prescribe and dispense.
Now that electronic prescribing (ePrescribing) has become the norm for most other medications, it increasingly is being viewed as a solution to reduce the costs, inefficiencies and administrative burdens associated with specialty prescribing as it is being done today. The industry is stepping up to build on the base that has been created for regular ePrescribing and pave the way for specialty ePrescribing.
Drivers. Arguing that there must be a better way, stakeholders are looking to specialty ePrescribing to help balance the high costs of specialty drugs versus their many benefits as well as streamline processes and reduce administrative overhead. A number of drivers and forces have created a compelling case for making specialty ePrescribing a mainstream process for medication management. They include:
Costs. ePrescribing can help all stakeholders monitor and control specialty drug spending, which represents the fastest growing segment among health care expenditures. Specialty medication outlays are expected to quadruple to $402 billion by 2020, and account for 50% of overall drug costs by 2018 for commercially insured individuals. These drugs are expensive, with costs per month generally ranging from $2,500 to $50,000 per patient. Eight of the 10 highest revenue drugs in 2016 will be specialty medications. Moreover, the cost curve continues to climb as new blockbuster therapies come on the market. Medicare soon will cover a bioengineered treatment for an aggressive kind of leukemia that will run $178,000 for two 28-day treatment cycles. Gene-based drugs under development for hemophilia B could soar to seven figures.
Reduced inefficiencies from outmoded processes. Rather than being a single transaction, specialty prescribing involves a series of transactions done mostly by outmoded paper, phone and fax processes. These create administrative burdens and work-flow inefficiencies for both prescribers and pharmacies. ePrescribing can eliminate these tedious and time-consuming manual processes, dramatically reducing administrative costs and improving work flow at the points of prescribing and dispensing.
Improved patient safety. Specialty ePrescribing can improve first fill rates, facilitate renewals and reduce medication noncompliance all of which can save money and improve outcomes and safety. For example, medication nonadherence results in 100,000 unnecessary deaths and costs $200 billion each year. Specialty ePrescribing also is expected to reduce cumulative time lags resulting from todays outmoded and time-consuming processes. These delays mean that fewer patients are served and needy patients may go without their medications. In fact, it currently takes an average of 3-6 weeks for patients to receive their specialty medication after it is prescribed.
More specialty medications are coming. New specialty therapies are rapidly coming onto the market, including biosimilars (which are not to be confused with generics) and expensive, new drugs for such conditions as hepatitis C and cancer. Two-thirds of new FDA approvals are now for specialty drugs. As mentioned previously, these could come with eye-popping price tags, which could be budget busters for payers and patients alike.
More patients will need specialty medications. The chronically ill are most likely to need specialty medications, and their number is on the rise. According to government data, about half of all adults 117 million people had one or more chronic health conditions as of 2012, and a quarter of adults had two or more chronic health conditions. By 2020, about 157 million Americans will be afflicted by chronic illnesses. That number is projected to increase by more than 1% per year by 2030, resulting in an estimated chronically ill population of 171 million.
Building blocks are in place. As a result of these and other factors, specialty ePrescribing is rapidly coming on the radar. The industry has been proactive in anticipating needs for specialty ePrescribing and building on the firm base that has been created for regular ePrescribing. The way has been paved to support specialty ePrescribing, such as:
* A robust infrastructure is in place, with 80% of physicians ePrescribing, some 700 electronic health records (EHRs) enabled to handle ePrescribing transactions and nearly all pharmacies able to receive and process ePrescriptions.
* The SCRIPT standard from the National Council for Prescription Drug Programs (NCPDP) is designed to accommodate necessary data elements, including drug name, dosage, quantity and dosing instructions.
* Insurance eligibility is determined before the patient arrives at the physicians office.
* Formulary and some benefit information are presented to the prescriber before drug selection.
* Prior authorization (PA) a necessary requirement for most specialty prescribing can now be done electronically through the NCPDP SCRIPT standard. Prescribers can complete PA at the point of prescribing eliminating the need for a pharmacy go-between.
The industry steps up to fill the gaps. Industry initiatives also are addressing other needs for specialty ePrescribing. NCPDP has been proactive in identifying and addressing standards and transactional needs for specialty ePrescribing. Members recently voted to add a range of fields to the SCRIPT standard to accommodate information that will greatly enhance the utility and usability of specialty ePrescribing. These include: agency and service information, which will allow a provider to indicate the preferred agency and type of service; hospice indicator; IV administration information and additional patient demographic information.
NCPDP also is working to address data elements that are critical to the safe, appropriate and timely ePrescribing of specialty medications. Diagnosis, lab values, height, weight, allergies and other indicators are needed to verify the appropriateness of a prescribed drug and ensure correct dosing. Patient contact information facilitates delivery and clinical services and enrolls the patient in assistance programs. The status of a PA request is key to reducing billing issues and expediting delivery of a specialty medication.
NCPDP also has been active in developing standards for streamlining and standardizing Risk Evaluation and Mitigation Strategies (REMS), which are required for many specialty medications. Automation of REMS protocols will minimize delays for additional safety studies as well as increase accuracy of data provided, lower costs to submit and collect data, and create an improved audit trail through the process.
Whats next? Although much has been accomplished, there still is more work to do in order for specialty ePrescribing to become reality. Opportunities exist for virtually every stakeholder.
Providers need to understand the value proposition for specialty ePrescribing, which includes better work flow, reduced overhead, improved quality of care and patient safety.
Payers and pharmacy benefit managers (PBMs) could better identify PA needs in the formulary and benefit information they provide to ePrescribing vendors. For example, few PBMs identify all PA drugs in their formulary data. Increased use of PA indicators could lead to identifying the need for PA in the physicians office, rather than at the pharmacy after the prescription has been written. Faster turnaround of PAs and more streamlined processes are needed by both providers and specialty pharmacies. Payers and PBMs also need to provide more timely updates to specialty formularies as well as provide access to participating specialty pharmacy networks.
Standards developers and vendors need to create needed infrastructure modifications and enhancements. For example, additional data fields are needed for fulfillment of specialty medications. ePrescribing systems should offer physicians a larger choice of specialty drugs than may be currently presented.
Point-of-Care Partners is working closely with the wide range of stakeholders to move ePrescribing of specialty medications forward and monitor progress. Let us know if we can give you an in-depth picture of the opportunities and challenges.