NASP: Specialty Medication Benefits Must be Thoroughly Vetted

The modernization of Medicare, Medicaid and every other government health program has caused the national health care market to change.

As consolidation and integration of health care occurs in rural areas, it does so to the detriment of patients, whose futures will be impacted by the choices that lead to fewer options for care.

A challenge by way of example is labeled as “vertical integration." Vertical integration can take the consumer out of consumerism. In other words, it is now more common than ever before that when a health benefit is offered, there is a high likelihood that if you have a mail order benefit, or a specialty benefit, that these services will be provided by the manager of your pharmacy benefit.

This may not sound like a big deal but it could mean the difference between picking up your medication order at your local pharmacy versus having it delivered by an out-of-state pharmacy.

This is particularly troublesome for patients in need of the life-saving and life-sustaining specialty medications used to treat those with chronic illnesses and rare diseases. Therefore, the main point to convey here is the paramount importance of making sure that the management of a specialty medication benefit for patients must be thoroughly vetted, from start to finish.

Welcome to Specialty Pharmacy

Specialty pharmacy is like the quarterback for care, seamlessly coordinating what happens with the patient, doctors, drugs, and pharmacy to beat a staunch opponent: diseases that are chronic, rare, progressive, debilitating, or fatal if left untreated or undertreated.

Navigating the world of treatment for a chronic or life-threatening disease can be complex and frightening. After receiving a terrible diagnosis, patients shouldn’t have the added burden of feeling that they are fighting the disease alone, or the worry of bankrupting their family to cover the costs of therapy.

There is an emerging and growing complexity that the public may not realize. There are well more than 155 medications available in the United States that treat these types of conditions, which are called limited distribution medications.

Simply, that means that not every specialty pharmacy has access to every drug; rather it's predicated on the arrangement with manufacturers, who decide which pharmacies can dispense their medications.This is a whole different side of healthcare that is growing and it is based on the deep experience and expertise that a specialty pharmacy may hold in a given field of care, including proper delivery and management based on protocol for each unique medication and/or condition.

Specialty pharmacy serves as the backbone for patients when they need it the most, providing the patient-centric treatment and essential support needed for patients battling tough diseases. According to the Drug Channels Institute and other sources, specialty pharmacy drugs will represent 44% of US drug expenditures by the year 2020, but yet will be used by approximately 2% of the US population.

Specialty pharmacists do more than dispense prescriptions; they are subject matter experts with levels of accreditation and certifications within certain conditions and disease states, which allows specialty practitioners the know-how to properly manage a patient on a specific medication for specialized condition.

Work with specialty pharmacy is important to ensure continuity-of-care, without disruption of service, so patients remain healthy and satisfied with treatments and suffer no consequences associated with increased costs. The alternative to such a high standard, high-touch level of care is the threat of completely unnecessary hospitalizations.

Illnesses treated by specialty drugs include cancer, hepatitis C, infectious diseases, infertility, Crohn’s disease, rheumatoid arthritis, psoriasis, HIV/AIDS, multiple sclerosis, cystic fibrosis, organ transplantation, human growth hormone deficiencies, hemophilia, and other bleeding disorders. Specialty pharmacy helps patients with these challenging disease states to stay on their drugs, despite sometimes painful and debilitating side effects.

The primary goal for specialty pharmacy is to ensure patients receive the right drug, at the right time, in the right dosage, and at the right intervals. Under no circumstances should a patient receive a medication that is “automatically” filled from a specialty pharmacy; instead it is quite the opposite.

As the number of health care options for patients continues to erode across the country, we must be mindful of the effect on patient outcomes—especially those with debilitating diseases that require an additional level of “white glove” care, from premature newborns struggling just to survive, to seniors nearing the end of a long, productive life.

Americans with serious health conditions should not face barriers to the care that they, their physicians, and their pharmacists determine is best for them. We are committed to working with all stakeholders and policymakers to ensure that these cost-effective and life-saving medications are carefully, effectively and efficiently furnished to those who need them.

About the Author

Mike Agostino is the Vice President of Pharmacy Innovation and Business Development for Hy-Vee, and serves on the Board of Directors for the National Association of Specialty Pharmacy (NASP). The Association will convene its fourth annual meeting from Sept. 26 to Sept. 28 in Washington, D.C. (full agenda here).