The number of accredited specialty pharmacies continues to grow – from 378 to 1,207 since 2015 – and much of this growth is driven by health systems, which now make up about 39% of the total figure. But even though many health systems have some sort of specialty pharmacy, most still have quite a bit of untapped potential. When properly implemented, specialty pharmacy can touch and improve all other areas of your health system, including infusion care services, 340B program performance, system-wide financials, and more.
Here is a look at what a specialty pharmacy is and how adding this service to your health system can have long-lasting, far-reaching advantages.
What is a specialty pharmacy?
A specialty pharmacy provides very high-cost medications used to treat rare or complex health problems. In many cases, specialty products are used by fewer people, so local pharmacies likely don’t have them in stock or cannot supply them due to payer or manufacturer restrictions. This is where a specialty pharmacy comes in.
Specialty vs. Non-specialty products
Non-specialty products constitute the vast majority (>99%) of prescriptions filled by consumers nationally. From the retail or community pharmacy perspective, they are primarily volume-driven and usually result in very minimal or even lost profit margin. Because of this, many independent pharmacies have been struggling to turn a profit.
Specialty products, on the other hand, constitute less than 1% of total prescription volume but account for over 50% of the nation’s drug spend. Due to their high cost, pharmacy profit margins can be substantial once an organization establishes specialty pharmacy services, collaborates with clinics, and increases their patient recruitment and retention.
Key variables that might make a product a “specialty product” include:
- They are disease-state focused. For example, the core drug therapies for oncology, rheumatology, gastroenterology, and endocrinology are specialty products.
- They involve a drug approval process, wherein the FDA might say the product has dangerous side-effects that require additional screening.
- As part of the above process, the manufacturer has to certify pharmacies to provide the products. If a drug is approved with a risk evaluation and mitigation strategies (REMS) program, the manufacturer may have to certify specific pharmacies, which inherently creates a smaller network of pharmacies that would be included.
As a general rule of thumb, if a drug is particularly expensive, it is most likely a specialty product.
Why should health systems have specialty pharmacies?
Reasons to add a specialty pharmacy to your health system include:
- Improved financial performance and a new source of revenue for the organization
- Improved patient care with the ability to holistically manage complex patients within the health system between provider and pharmacy.
- Improved efficiency in the ability to serve patients within the health system to ensure their drugs get to them before they leave the hospital.
- Increased provider visibility into patient care by delivering specialty products within the health system to help providers know what is going on between visits (rather than waiting nine months between visits to get an update).
- Specialty pharmacy provides visibility into every aspect of care, as everything is documented internally, including information on side-effects and adherence problems.
- Improved clinic and provider efficiency by offloading complex prior authorization and insurance-related paperwork out of the clinics and to highly skilled and lower-cost pharmacy personnel.
Visante’s approach to specialty pharmacy
At Visante, our clients are our partners, and we believe holistically that the internal health system’s specialty pharmacy business model is best for patients and for health systems. Unlike our competition, we quickly develop clients to the point of self-sufficiency and high performance via our customized implementation service model.
We support health systems to implement and manage all aspects of their internal program in a manner which maximizes early and long-term financial returns. We recognize that no two programs are exactly alike, and we take pride in developing customized solutions for clients that are highly configured to their environment.
Our goal with our specialty pharmacy services is simple: to drive value for health systems in terms of their specialty pharmacy performance while improving patient care and solving a workforce need in the marketplace.
Contact us today to learn more.
IQVIA has released their 2022 Report on the Use of Medicines and as usual it is jam packed with great information. Three key things you should know:
- Prescription drug expenses are continuing to rise at a very significant rate.
- Specialty pharmaceuticals now comprise over 50% of the U.S. drug spend .
- Prescription abandonment is an important yet “hidden” problem.
Additional data and trends include:
- Retail drugs currently represent 86% of medicine use in the U.S. and non-retail drugs are only 14% of use, a number that has been declining since 2017. These statistics are very consistent with what we see in our practice. For our 60 largest IDNs, health systems and hospital clients, outpatient drug spend now exceeds inpatient drug expense. This situation emphasizes the need for an overall pharmacy strategy that looks beyond pharmacy as a “cost center” and recognizes the significant contribution to revenue and operating margin that well-run retail, specialty and infusion programs can generate. It also emphasizes the growing importance of ambulatory pharmacy patient care services to assure patients are on the right drugs, off the wrong ones, and adherent to their regimens to prevent costly drug related hospital admissions.
- In total, dispensed prescriptions increased at an average 2.1% over the past five years with minimal impacts due to the pandemic. Prescription growth has been driven by the aging population as seniors use more medicines per capita than other age groups, and the 65+ population has grown on average 3.6% annually 2017- 2021. In our experience, each senior typically has at least one chronic condition and each chronic condition generates on average of two prescriptions. Projections are that by 2030, fully 30% of the U.S. population will be classified as seniors. This trend certainly points toward continued growth in the retail prescription market and the need for health systems to have a coordinated strategy around retail/specialty pharmacy and population health/disease management programs.
- While the percent of prescriptions distributed at retail pharmacies has grown 12% since 2017, mail order prescriptions have declined 4% despite a slight increase in 2020 due to shifts to mail order. The emergence of major players in the mail order prescription space, like Amazon, were expected to create some significant market shifts. However, as evidenced by these data, those shifts have failed to materialize. As a result, there is a continuing opportunity for hospital-based retail/specialty programs. With the increased need for chronic conditions management, hospital-based programs are in a great position to be able to provide fully integrated, longitudinal care for these patients which includes their prescription needs. Being able to fill retail/specialty prescriptions through hospital-based programs provides access to key medication-related data that is vital to an overall patient management approach.
- Specialty medicines now account for 56% of spending, up from 28% in 2011 and driven by growth in autoimmune, oncology and diabetes use. While specialty medicines now account for the majority of the prescription drug spend, they still represent less than 5% of total prescription volume. These data highlight the need for a robust hospital strategy around specialty medications that can help control expense on the inpatient side and optimize revenue/margin on the outpatient side. Understanding growth trends in populations that rely on specialty medications, and keeping ahead of the release of new specialty agents, is imperative for overall hospital success as this class of medications continues to grow.
- Reflecting the growing number of people seeking care for mental health disorders in the U.S , prescriptions for mental health disorders grew 5.5% in 2021 and 7.6% in 2020, an increase of more than 64Mn prescriptions in two years. Providing care for this rapidly growing segment remains a challenge for many organizations, but these data point toward continuing growth in this market segment.
- Drugs remain one of the fastest growing elements of U.S. healthcare spending. Over the past five years, spending at list prices [Wholesaler Acquisition Cost (WAC)] has increased from $581Bn to $776Bn — an average of 5.9% per year. Payer net spending has increased from $463Bn to $586Bn over five years at a compound annual growth rate of 4.8%. Spending at manufacturer net prices, including all products, are estimated to have grown an average of 4.6% over five years and 12.1% from 2020 to 2021, including $26Bn of growth from COVID-19 vaccines and therapeutics. In our experience, hospital and health systems are often under resourced in terms of business infrastructure, supply chain management and analytics to most effectively track and manage this growing expense. As hospital margins continue to be squeezed, investing in the infrastructure to optimize the management of pharmaceuticals continues to make good business sense.
- In 2021, use of opioids declined by 6.9%, dropping back to per capita levels of use seen in the middle of the year 2000. While this is great progress, the issue of opioid related deaths is far from controlled. Data from CDC’s National Center for Health Statistics indicate that there were an estimated 100,306 drug overdose deaths in the United States during 12-month period ending in April 2021, an increase of 28.5% from the 78,056 deaths during the same period the year before. Clearly this issue involves more than just controlling prescription opioid use and given the primary focus on the pandemic the past two years organizations should not lose sight of the continuing need to improve in this area.
- 81Mn new prescriptions were abandoned at the pharmacy in 2021 by patients. Of prescriptions with a final cost above $250, 61% are not picked up by patients, as compared with 7% of patients who do not fill when the cost is less than $10. When examining causes for 30-day readmissions failure to take prescribed medication is often a major driver of readmission with several studies showing this to be 25-30% of the total readmission volume. Ensuring an effective discharge medication reconciliation and discharge prescription capture program supported by a well-developed patient medication assistance program are sound strategies to address this opportunity.
While these are just a few of the key data points from the IQVIA report, they do highlight the continued importance of medications for effective outcome, expense and revenue management for hospitals and health system. Having a high-performance pharmacy system in place to optimize all aspects of medication use is critical and will continue to increase in importance as part of an overall strategy for hospital and health system success.
Join Steve Rough and Joe Cesarz, as they discuss the importance of focusing on specialty pharmacy services.
Join Jim Jorgenson, MS, RPh, FASHP, CEO, as he discusses what specialty pharmacy is and how every organization should have a defined strategy for how they plan on managing specialty pharmaceuticals.