Specialty Pharmacy

Specialty Pharmacies Seek Ways to Deliver Financial and Clinical Outcomes to Payers

Reprinted from the July 2005 issue of 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.

One overwhelming buzzword at the Pharmaceutical Care Management Association's first-ever Specialty Pharmacy Symposium, held June 13-14 in New York, was outcomes. "Payers want improved outcomes, and that's becoming the goal for all 'four Ps:' payers, providers, patients and product manufacturers," said consultant Debra Stern, vice president of Rxperts, Inc. Health plans and employers, in particular, are asking specialty pharmacies to demonstrate the value of new injectable and infusible medications, and specialty pharmacy providers (SPPs) are seeking ways to satisfy their clients, added Steve Russek, vice president of clinical product development at Medco Specialty Solutions.

One form of clinical outcomes data is the rate of therapy adherence achieved over a period of time. Specialty pharmacy experts continued to assert that chronically ill patients can achieve much higher rates of medication compliance and adherence in specialty pharmacy than in the traditional retail or mail-order settings. In addition to adherence and compliance rates, SPPs can also demonstrate financial and clinical outcomes relating to the implementation of preferred formularies, the use of medication waste programs and the avoidance of costly emergency room (ER) and hospital visits.

Here's how five leading SPPs are demonstrating outcomes to clients in various disease states:

• Hepatitis C. The goal of CuraScript Pharmacy Inc.'s hepatitis C program is to improve therapy adherence, which results in sustained viral response, according to Rosemary McDermott, senior vice president of clinical services. From patient adherence surveys to scheduled clinical assessments with a clinician, CuraScript steps in at several key points during a hepatitis C patient's 24-to-48-week therapy.

According to first-year results for a 410,000-member health plan presented by McDermott, the unidentified CuraScript client saved approximately 2.5% on total specialty claims, which were initially about $19 million, through hepatitis C utilization management. About 69% of those savings came from avoiding inappropriate requests for therapy, 30% came from preventing inappropriate therapy continuation, and 1% came from delegating administration services to the specialty pharmacy, she said. Part of CuraScript's intervention process involves monitoring ongoing therapy to make sure patients still meet the initial coverage criteria, monitoring side effects and/or identifying any major compliance issues, McDermott told SPN in a June 21 follow-up phone interview.

In 2004, McDermott said the same client saved a total of $495,180 through utilization management (which contributed to 90% of savings), formulary management (6%), administrative clinical management (3%) and improved clinical outcomes (1%). The savings from administrative clinical management reflect the use of CuraScript's nurses, pharmacists and social workers as a value-added service, which saved the client money by not having to hire extra people to manage hepatitis C patients.

The client also obtained a total of $36,660 in rebates from formulary management.

• Multiple sclerosis (MS). Of the estimated 500,000 MS patients in the U.S., an estimated 20% have been on therapy but have stopped for some reason, according to Priority Healthcare Corp. Director of Clinical Services Pam DuVaul. Patients often have an unrealistic expectation of their MS therapy and are likely to drop off their interferon injections because they don't feel like they're getting better, she suggested. From flu-like symptoms to the misconception that the medication isn't working, patients "talk themselves into" taking a break from their therapy, she said.

As a result, specialty pharmacy addresses the reasons for noncompliance and achieves savings for the payer by helping to avoid the consequences of noncompliance. For example, the mean unit cost in 2002 of a "low-intensity" relapse or flare-up, which could result in physician office visits and symptom-related medications, was $243 per patient, according to Priority. And the mean unit cost of a "high-intensity" episode, which could result in hospitalization and post-discharge rehabilitation, was $12,870 per patient.

Meanwhile, adherence rates achieved by Priority are around 98% for Avonex and Rebif, which have both been shown to slow the progression of disability, according to DuVaul. Adherence rates for Copaxone and Betaseron, the other two common MS therapies, are around 95%. While DuVaul didn't have an adherence rate for MS therapy at the retail level, she noted that one in five patients receiving therapy outside of specialty pharmacy is likely to stop treatment.

• Pulmonary arterial hypertension (PAH). Since this rare and potentially fatal disease requires continuous infusion, patients must be taught to self-infuse and must have a good support network in place, recommended Janelle Szymanski, a cardiopulmonary nurse specialist with Accredo Therapeutics. Before Accredo patients are discharged from the hospital, they go through intensive training with a PAH program nurse. That same nurse also makes follow-up phone calls or visits with patients post-discharge, and an Accredo pharmacist does clinical assessments with patients to give them any needed therapy counseling and make sure they have enough medication.

The primary goal of the program, however, is for patients to be "completely independent with their therapy," said Szymanski. "That's from mixing Flolan to caring for their central line, and we've typically been able to do that within seven to 10 days of discharge from the hospital."

According to Szymanski, a retrospective one-year study of random Flolan patients determined the volume of calls to Accredo's 24-hour nurse support center that prevented an ER visit or hospital admission, and found that payers saved an estimated $6,552 per patient per year by preventing physician and ER visits (e.g., by handling a pump problem or central line issue). The study also found that payers saved an estimated $43,281 per patient per year by avoiding hospital admissions, she said.

Through Accredo's interventions, patients also had a central-line infection rate of .044 per patient per year, compared with the national average of .45 per patient per year. And the compliance rate for Flolan patients is 99.9%, added Szymanski.

• Hemophilia. To treat hemophilia and related bleeding disorders, the annualized per-patient costs just for factor replacement can exceed $100,000. And hospital costs relating to bleeds and/or joint damage can be far greater. Financial outcomes relating to hemophilia management can be shown by how "close to the dose" therapies are delivered, and by a reduction in costly ER and hospital visits, according to Jay Bryant-Wimp, product manager for Hemophilia Options, a division of Option Care, Inc. Clinical outcomes can be seen in improved therapy adherence rates, he added.

Bryant-Wimp relayed the story of an ideal candidate for a hemophilia management program — a 27-year-old male with severe hemophilia A, HIV and knee and ankle debilitation. This patient was receiving factor through a mail-order company that would send nurses to his home, and he would routinely "fire" his nurses and end up in the ER approximately six to 12 times a year. In addition, Hemophilia Options found he stockpiled $500,000 worth of unused medications in his basement.

As a result, Hemophilia Options assembled an intervention team made up of the patient's physician, a hemophilia treatment center, and a direct home health team and took him through the "empowerment process" needed to improve adherence and avoid medication waste. Various sources, including a visiting nurse and a "care coordinator," collected data over the course of treatment, making sure the patient was infusing his medication properly and had enough — but not too much — factor.

After three years with Hemophilia Options, the 27-year-old patient's factor adherence rate ended up being 96%, compared with an estimated 45% to 50% before joining the program, Bryant-Wimp said. The patient also had no ER visits in that time period, as opposed to 27 visits during the three years prior. And the company effectively managed waste by distributing 900,759 units for the 889,200 doses prescribed (doses within 1.67% of prescribed dose), he added.

• Rheumatoid arthritis (RA). Caremark Rx, Inc. Director of Strategic Analytic Services Andrea Marks says, RA patients have three times the direct medical costs, twice the hospitalization rate and 10 times the work disability rate of an age- and sex-matched population.

Through a combination of physician support, proactive scheduling, care coordination, medication management, pharmacist counseling, self-injection training and medication and condition education, Caremark's RA management program leads to improved adherence and reduced medical costs, said Marks. According to 2004 Caremark outcomes and analysis data, medication compliance for individuals enrolled in the RA management program averages 97%, compared with 78% compliance in a retail pharmacy setting. And adherence rates for Caremark RA patients are 89% vs. 80% at retail.

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