Specialty Pharmacy

Featured Health Business Daily Story May 2008

Health Plans Are Urged to Demand More from Specialty Pharmacies in Therapy Management

Reprinted from SPECIALTY PHARMACY NEWS, a monthly newsletter designed to help health plans, PBMs, providers and employers manage costs more aggressively and deliver biotechs and injectables more effectively.

By Angela Maas, Managing Editor (amaas@aispub.com)

When the Medicare Part D program started a few years ago, there was a lot of focus on the medication therapy management (MTM) requirement. Now, with the publication of various study results on what approaches are effective and what aren’t, it’s a good time for health plans to take some of these best practices and apply them to specialty pharmacy.

As utilization of specialty drugs rises and the pharma pipeline burgeons with new market entries, it is imperative that health plans make sure not only that the correct patients are receiving the correct drugs but also that these patients comply with their therapies. Because many of the drugs require lifelong treatment regimens, this is a tall demand. And it is complicated further by the increasing availability of targeted therapies. Still, industry experts contend that specialty pharmacies are in the optimum position to both provide and manage these therapies.

MTM programs, also referred to as specialty therapy management (STM) programs when applied to specialty drugs, focus on meeting primary objectives and producing superior outcomes for patients.

“Nowhere is the need for STM programs greater than in the use of specialty pharmaceuticals,” asserts Russ Allinson, a principal with consulting firm Therigy, LLC. While these drugs, when used correctly, can produce tremendous clinical responses, when they are not prescribed or used correctly, “the financial impact is worse than doing nothing.”

According to Allinson and Joe Morse, also a principal with Therigy, “When implemented and executed properly, the STM program will require a longitudinal record of the pharmacy care that is provided and the results of that care.”

“Specialty pharmacies in the past have been selling services based on the ability to perform patient-support services,” says Morse. But lately, “we have been seeing the degradation of services and fewer services provided.”

“A certain amount of cynicism in the market” contributes to the problem, maintains Allinson — payers believe that there are no data to prove STM’s value, he says, but specialty pharmacies claim that they are not paid to perform this task.

“Specialty MTM can be a customized, patient-specific program instead of a broad, sweeping program developed for a mass number of patients,” says Mark Leeper, staff vice president for market and clinical program development for PrecisionRx Specialty Solutions, WellPoint, Inc.’s specialty pharmacy. Disease states such as multiple sclerosis, Gaucher’s disease, cancer, hemophilia, hepatitis C and respiratory syncytial virus, as well as immune therapy, transplant, growth hormone and enzyme replacement drugs, lend themselves to STM programs, he says.

Leeper recommends that plans “focus on identifying the types of programs the specialty pharmacy offers; what features they have; how they benefit the member, physician and health plan; and how results are measured.”

“Chronic, incurable diseases must be measured by outcomes,” says Enoch Strollo, vice president of sales and marketing for BioPlus Specialty Pharmacy Services. “How many interventions did the specialty pharmacy have with the patient? This is a number that can be calculated into savings.”

Build In Costs or Pay as You Go

Plans either can opt for having STM costs built into the price of its specialty pharmacy agreement or can choose to pay those fees as they go, he says. Most insurers tend to take the former approach. “There are many options to compensating for MTM — it is just a matter of coming to terms with what is going to work best for the goals of the plan.”

“The costs for effective MTM programs are built in the operating expenses of a good specialty pharmacy,” explains Strollo. “Programs should not need to be carved out.”

With STM programs, “it is reasonable,” he says, for plans “to expect something unique. After all, specialty pharmacy is a unique service. A specialty pharmacy should offer more than retail or mail order. It is reasonable to expect that a plan would see an overall profit increase due to total services [by the specialty pharmacy going up, resulting in greater compliance], not just an AWP [i.e., average wholesale price] minus savings.” Further evidence of profits, he adds, can be seen through a decrease in emergency-room and physician visits and hospitalizations.

“The ROI [i.e., return on investment] that has been seen with MTM services varies from 2:1 to 12:1,” says Kari Amundson, director of specialty pharmacy services at Fairview Pharmacy Services LLC, a division of Fairview Health Services. “The model that supported the 12:1 ROI was with face-to-face visits where pharmacists provided care working in collaboration with the patients’ providers. Savings shown were in total health care expenditures. HEDIS [i.e., Healthcare Effectiveness Data and Information Set] measures improved as well, along with patients’ goals of therapy.”

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