The Role of Specialty Pharmacies in the Dispensing Process

Peter Salgo, MD: Let’s talk about specialty pharmacies, if we can, for a minute. I have a number here, about half of all the oral oncolytics are dispensed by specialty pharmacies. My understanding is there aren’t a lot of specialty pharmacies in this country, and they’re not distributed evenly across urban and rural areas. So some patients may have difficulties getting to them. What are the real challenges in the supply chain here in specialty pharmacies versus all-comers?

Noa Biran, MD: For the most part patients can receive drugs from any specialty pharmacy. These drugs are generally shipped. The patients don’t go and pick up the drugs, so I don’t see it as a negative in terms of if you’re not close to a pharmacy. But there are not a lot of pharmacies that we personally deal with. There’s maybe 2 or 3.

Cheryl Allen, BPharm, MBA: You’re right, as far as pharmacies, there are 65,000 pharmacies in the United States. Specialty pharmacies, if we define them by the pharmacies that are either URAC accredited or in the process, there are probably about 650. Of those 650, those that practice in the oncology space are a handful of maybe 25, 30.

Peter Salgo, MD: Let me see—25 or 30 of these specialty pharmacies are in the oncology space. By the way, it didn’t escape my notion, my attention, that she said I was right. It doesn’t happen that often. But, nice to be right.

You’ve got a very small number.

Cheryl Allen, BPharm, MBA: Yes.

Peter Salgo, MD: Of these specialty pharmacies.

Cheryl Allen, BPharm, MBA: That have an oncology expertise. And I think that if you look at the oral oncolytics, as Dr. Biran said, these are tough therapies for the patients. The patients are self-administering. Many times this is a complicated dosing regimen where we have pulse therapy, with dexamethasone. They’re dealing with adverse effects.

Noa Biran, MD: One of them is Monday, Wednesday, Friday, then a week off, then Monday, Wednesday, Friday. Give that to an 89-year-old lady.

Peter Salgo, MD: Wait, you’re telling me…

Noa Biran, MD: With injections interspersed.

Peter Salgo, MD: But there aren’t that many pharmacies. There aren’t that many specialty pharmacies. And you’re telling me they just deliver, you know, “ding-dong, here’s your pills.” Isn’t that a problem?

Cheryl Allen, BPharm, MBA: No, it’s way more than “ding-dong, here’s your pills.” There are patient care coordinators, nurses, and pharmacists working with these patients.

Peter Salgo, MD: But I come back to the geographic distribution of these places. There’s very few of them. And if you live 500 miles away, I’m making up a number, I don’t know.

Cheryl Allen, BPharm, MBA: Yes, we have patients in Alaska, we have patients in Guam, we have patients all over.

Peter Salgo, MD: So how do they deal with this complicated stuff with the specialty pharmacy so far away?

Cheryl Allen, BPharm, MBA: Within the specialty pharmacy space we’re generally working with our folks on the front end providing them with motivational interviewing, training to learn the techniques to develop the relationships with our patients, because we develop the relationship with a patient over the phone. And the patient has to clearly understand, patient and sometimes the caregiver, what our role is, how we will help to support them, how we will help to keep the prescriber informed on what’s happening. Because likely we will get the call that maybe there’s an adverse effect. Or if there’s an adverse event or something that happens.

Peter Salgo, MD: But again, it’s on the phone. Isn’t it better one-on-one? Wouldn’t it be better if they were close to the patient and they could answer questions person-to-person?

Cheryl Allen, BPharm, MBA: The provider, the physicians, the NPs [nurse practitioners], the clinicians, the PAs [physician assistants] need to be on the front end, if they’re prescribing a drug, they need to be dealing with the adverse effects in the day-to-day.

Peter Salgo, MD: There are 2 questions that I come up with. One, do we need specialty pharmacies to do this or can we train all pharmacies to do it so that we get geographical distribution? Or 2, maybe this should be in-office prescription dispensing in a doctor’s office and you don’t need a pharmacy at all.

Cheryl Allen, BPharm, MBA: We have that, in-office-dispensing, and that’s apportioned whether it’s in an individual prescriber office, whether it’s a hospital or health system that may have access to these drugs. And again, we’re talking about drugs that are limited distribution. And when a manufacturer decides to limit the distribution—the manufacturer, not the payer—but when the manufacturer decides on the pharmacies that they’ll put their drug into, largely it’s because of supply chain management, right? So we’re dealing with.

Noa Biran, MD: Ten-thousand-dollar drugs.

Cheryl Allen, BPharm, MBA: Right.

Noa Biran, MD: Your local CVS doesn’t want to keep those on stock, you know?

Peter Salgo, MD: My local CVS doesn’t have a lot of stuff that I would like to see them have. I don’t want to dump on CVS at the moment, but I guess what I’m really asking is this. Yes, a specialty pharmacy with the specialty expertise makes sense, unless you’re 500 miles away, but everybody who’s getting these drugs has a physician. Everybody has some oncologist specialist.

Noa Biran, MD: Right.

Peter Salgo, MD: Why not just say, broaden your practice; all you oncologists out there who see your patients, you dispense the drugs. Why can’t we do that? Do you dispense drugs?

Noa Biran, MD: I do not. I can see people feeling there’s a conflict of interest and a change in prescribing patterns.

Peter Salgo, MD: In what sense? You’d only prescribe those drugs that you can dispense, is that what you’re suggesting?

Noa Biran, MD: Yes. Some physicians may be more inclined to prescribe drugs that they are dispensing.

Peter Salgo, MD: Well that would be unethical. That would be a bad thing.

Cheryl Allen, BPharm, MBA: I think you have some good proxies in this space. You have Florida Cancer Specialists with Rx To Go; you have Tennessee Oncology, Texas Oncology. So there are some practices, large practices that have a model where they created in essence their own pharmacies within their organization.

Peter Salgo, MD: Sure.

Cheryl Allen, BPharm, MBA: So can it work? Yes, and it works well. Where there are some problems, it would be where that site isn’t recognized by the payer, right?

Peter Salgo, MD: There we go again.

Cheryl Allen, BPharm, MBA: And so there we go back to that, right?

Peter Salgo, MD: Well, if the payer is going to recognize a specialty pharmacy, why can’t you get the payer to recognize an in-office dispensary?

Cheryl Allen, BPharm, MBA: It’s the same reason I think that the manufacturers are looking to limited numbers of pharmacies. It’s a limited number of stakeholders to deal with, right? So how many in-office dispensers would we have in a country?

Peter Salgo, MD: I don’t know. How many oncologists deal with multiple myeloma in this country?

Noa Biran, MD: Thousands.

Cheryl Allen, BPharm, MBA: Thousands.

Peter Salgo, MD: Thousands, OK. And they’re going to write prescriptions for these drugs. So what I’m hearing is, the specialty pharmacies are the hub. They’re the, and I don’t want to use the word valve or control or spigot, but they are the places where these thousands of physicians funnel these patients and there’s some sense of control. The manufacturers feel better this way, and the insurers feel better this way. Is that fair?

Cheryl Allen, BPharm, MBA: Well the manufacturers of the drugs that the manufacturer decides need to go into limited distribution. I think the other driving force is the payer. Does the payer contract with certain pharmacies that would drive the scripts into there? I think at the end of the day the pharmacy, they may get their first prescription from that prescriber office, but they’re not going to get the follow-up prescriptions if they’re not providing that good quality service. So you have an excellent organization where you have all of the touch points to help that patient to get access.

Peter Salgo, MD: We’ll call that Noa’s Army and keep going.

Cheryl Allen, BPharm, MBA: Yes.

Noa Biran, MD: They’re amazing.

Cheryl Allen, BPharm, MBA: It’s all about access to drug product. Some prescriber offices we deal with, there are 1 to 3 to 5 oncologists practicing together out in the community, and they don’t have the bandwidth to support all of that.

Peter Salgo, MD: I guess that’s what I was getting at.

Cheryl Allen, BPharm, MBA: So they lean on all of that back-office help, working on benefit investigation, doing prior authorizations, at times doing appeals, doing funding support. All of that is generally the staff within that specialty pharmacy, in addition to the folks on the front lines working with the patients.

Peter Salgo, MD: What I’m hearing is the specialty pharmacy is not just a drugstore. It’s a whole machine integrated into the delivery system for these very specific drugs. Is that fair?

Noa Biran, MD: Yes.

Peter Salgo, MD: Can, in your view, this work for patients who are geographically widely dispersed and often far away from these places?

Noa Biran, MD: Absolutely.

Peter Salgo, MD: How? I always thought you had to see patients face-to-face. No?

Noa Biran, MD: No. I think the person who’s prescribing the drug has to see the patient. There’s no way to replace that. You have to see the patient when you’re prescribing any kind of chemotherapy, especially an oral chemotherapy.

Peter Salgo, MD: Right.

Noa Biran, MD: But I think in terms of offices that don’t have the staff to support prescriptions and prior authorizations and funding for co-pays, it’s helpful to have a pharmacy that’s dealt with this drug a lot. Most physicians in the community see 1 patient a year with multiple myeloma, and have 1 or 2 patients on lenalidomide or POM [pomalidomide], or 0 patients on pomalidomide.