A Double-Edged Sword

Working together to contain the cost of expensive specialty medications and provide patients with what they need is the challenge we face in the world of specialty pharmacy.

The growth of specialty medications is like a double-edged sword in the health care arena. These medications offer tremendous promise for the treatment of serious, debilitating, and life-threatening conditions. The positive impact these medications are having on the lives of patients is the positive side—and the expansive cost of these medications is the downside.

The average specialty medication costs approximately $20,000 per year per patient, which is putting an enormous financial strain on our health care system. The need for specialty pharmacies for providing the best possible care for patients requiring specialty medications is evident. The question is “How can specialty pharmacy impact the health care system positively and not fragment care or confuse patients about their care?”

This brings a remarkable opportunity for community specialty pharmacies, where we can take a comprehensive approach in managing patients’ multiple disease states. It’s just as important for a patient to take his/her warfarin, insulin, propafenone, or levetiracetam as it is to take his/ her glatiramer or adalimumab. If the goal is to improve patients’ outcomes and reduce cost over the term of their illness, then must you not look at the complete picture?

In our specialty pharmacy practice, we offer individualized medication management programs and special packaging for our patients, including over-the-counter vitamins, supplements, and nutritional products. These programs are designed to ensure that our patients are compliant with all their medications.

The challenge that all community specialty pharmacies face is when payers, PBMs, and manufacturers limit or restrict the distribution of specialty medications. Across the country, specialty pharmacies offer tremendous programs and services to benefit patients. Therefore, specialty programs should not be controlled by the PBM industry alone, especially when glaring conflicts of interest exist between the customer (insurer) and its stockholders.

As an example, a PBM with more than $60 billion in revenue and more than $4.3 billion in profits has 2 marketing brochures—one that shows payers how it can save them money on specialty medication by using their own specialty pharmacy and managing the patient, and the other for Wall Street ensuring stockholders and investors that they will increase profits by increasing their specialty business.

Manufacturers choose closed distribution systems (limited distributed networks) to control inventory and data, and to comply with restrictive REMS, but in the process frustrate patients, hospitals, physicians, and retail providers. By only allowing a handful of providers to have access to the medication, manufacturers are limiting patient choice, a hallmark of our country’s freedom. We need to develop a better distribution channel where all qualified specialty pharmacies can have access to these medications, allowing the manufacturers inventory control and data without limiting patients’ rights and delaying the delivery of care.

We are all in this together. Insurers will need to address the rising costs associated with specialty medications. PBMs need to manage the specialty benefits for a payer. Manufacturers have developed wonderful support programs around these medications. And specialty pharmacies have developed programs to deliver these medications, while ensuring compliance and adherence to provide the best possible outcomes in improving our patients’ lives. I am certain that all the stakeholders will agree that the first priority is the patient.

With that in mind, we all need to work together in developing solutions that have a positive impact on patients while containing costs. One thing is certain: if we limit access to patients or mandate only using certain providers, it will not benefit our patients. SPT

Nicholas Karalis, RPh, is a specialty pharmacist and co-owner of Elwyn Specialty Care, which offers specialty pharmacy services in HIV, oncology, hepatitis C, multiple sclerosis, rheumatoid arthritis, Crohn’s disease, psoriasis, and other areas. A leading voice in community pharmacy, he is a founding member and board member of the Community Specialty Pharmacy Network, as well as a member of the Cardinal Health National Home Health Care Advisory Board. Mr. Karalis is an editorial board member of Specialty Pharmacy Times.