NASP 2019: A Doctor's Perspective on Specialty Pharmacy

The annual National Association of Specialty Pharmacy (NASP) meeting concluded on Thursday with a group of sessions on regulatory affairs. This was the first time I attended a conference focused on specialty pharmacy and I really didn’t know what to expect.

My perspective as a practicing internist who has dealt with pharmacy review organizations was, frankly, quite negative. From my point of view, I went to great trouble to make a diagnosis, consider the best treatments, figure out what I thought would be the best way to get the medication covered and I sent the prescription hoping for the best, but expecting the worst.

I had no idea what went on once I clicked “send” on my hand-held computer. Ignorance is dangerous and I really didn’t understand the process.

Writing prescriptions for new, expensive medications is a physician’s worst nightmare. It was natural, I previously thought, that pharmacy benefit managers (PBMs), review organizations, and specialty and retail pharmacies were all in a conspiracy to deny care in order to collect fees from payers.

Secondly, I assumed that the people to whom I was sending prescriptions were illiterates, taking their marching orders from scripts provided by payers. Thirdly, I didn’t separate PBMs from the specialty or retail pharmacies, and how their missions have been historically different.

Going forward, as these organizations vertically integrate, I suppose that relationship will become murkier. Lastly, I really didn’t acknowledge my part in the problem because I often failed to send the documents that were required.

Frankly, I found it insulting that they would question me. It should have dawned on me that nowhere in business can anyone at the bottom of the organization order $30,000 dollar purchases without some proof of justification. It also should have been obvious that the primary mission of pharmacists is to help the patients, not to take away all of the doctor’s responsibility in ensuring a smooth delivery of medication to them.

The annual NASP conference opened my eyes to the complexity of the system. I met dozens of dedicated and talented individuals who work in the specialty pharmacy industry and actually learned about what they do to help our patients.

If I had taken the trouble to make the dreaded phone call instead of delegating it or—even worse—ignoring it, I would have found the process to work much better. If I had taken the trouble to understand clinical guidelines prior to ordering new medications, it would have saved a lot of trouble. If our electronic medical record was directly connected to the pharmacy, it would have saved countless hours.

After attending the lecture on “smoke and mirrors” in reimbursement, my eyes were opened wide to the complexity of high drug costs. One solution I hear from politicians to the lower cost of medications is to import medications from Canada. Canada has approximately 10% of the population of the United States.

Do you think the Canadian government is thrilled with the notion of Americans depleting their supply of medications, which would create shortages and increase cost for Canadians? I was shocked to learn about direct and indirect remuneration fees and that 1000 pharmacies in the United States closed last year.

Attending the lectures on the state of care for multiple sclerosis, cystic fibrosis, and hepatology, I learned how many different medicines were available and how pharmacists had to be on top of every aspect of managing the prescription, the patient, and the doctor. I was impressed how informative the pharmacy presenters were and how committed they are to improve the supply line of medications to patients.

I was struck by the realization that we are all on the same side in that we are driven to find the best medicine for the right patient at the right price. I was quite impressed to learn how much trouble these pharmacy organizations experience to keep patients informed on the progress of their medication supply orders and how they remind them to remain compliant.

I knew that physicians don’t communicate well with each other, but I didn’t realize the scope of the miscommunication. We order medications while the patient’s other physicians are ordering medications that may conflict with each other or are redundant—and we don’t even know it. Physicians don’t communicate sufficiently and whether that is due to time constraints, contempt, or is just a sign of the times, I really don’t know. It’s actually shameful that this aspect of medical practice has gone away, but it’s an epidemic.

The keynote speakers—former acting Administrator of the Centers for Medicare and Medicaid Services Andy Slavitt and former NFL quarterback, current media personality, and cystic fibrosis patient advocate Boomer Esiason—made impassioned speeches, combined with humor, about the difficulties patients encounter trying to access medications. One takeaway was to keep fighting for what you believe is right for the patient.

Suggestions were made on ways to improve the problems in the system. Although I didn’t agree with everything said, I learned a great deal of pertinent information. I found out that there are now independent companies that test medications for purity, especially generic drugs. It was reported that up to 10% of generics do not contain the proper amount of a drug or are improperly manufactured so they don’t dissolve or are contaminated. This is a topic few stakeholders are talking about, certainly not in government, but it will become a bigger problem if it is not addressed.

To all those dedicated, often nameless practitioners in specialty and retail pharmacy, I want to say thank you.

Thank you for taking the care you do to help our patients. I hope we find ways to make your life easier. Keep up the fight. To the independent pharmacists, don’t quit. We need more mom and pop pharmacies, not more chains.

From a grumpy, old country doctor.

Simon D. Murray, MD