Combating Specialty Drug Challenges in the Pharmaceutical Industry

December 19, 2023 - The pharmaceutical industry has witnessed a significant rise in the utilization of specialty drugs in recent years, prompting a need for improved cost management and a streamlined patient experience. Specialty drugs, characterized by their high costs, complexity, and touchpoints, play a crucial role in treating chronic conditions. 

Specialty drugs, often biologics administered through injections or infusions, address historically limited treatment options. Despite their efficacy, these drugs contributed to 73% of medicine spending growth from 2011 to 2016. The fragmented experience in managing specialty drug costs poses challenges for providers. 

To address these issues, innovative solutions such as mail-order pharmacies, step therapy, cost-control tools, and medication synchronization have emerged to improve patient outcomes and streamline drug management. 

Understanding Specialty Drugs 

Specialty drugs, distinct for their high costs, have become pivotal in treating chronic diseases like cancer, rheumatoid arthritis, and multiple sclerosis. Biologics —  a significant category within specialty drugs — mimic compounds in the body, requiring active clinical management and patient support due to their complexity. 

Forecasts suggest that this year's FDA approvals will be largely driven by specialty drugs, constituting 80% of the total. This trend presents challenges for clinicians in staying abreast, underscoring the importance of effective management for payers and providers amid the escalating volume of specialty drugs. 

Challenges in Specialty Drug Management 

Specialty drugs, priced significantly higher than traditional counterparts, contribute to rising healthcare costs. A lack of synchronization between pharmacy and medical benefits and  increasing prescription costs hamper patient access. 

Nearly half of Americans (49%) have experienced challenges getting specialty medications, according to an August 2021 Rx Benefits survey. Almost 24% of these respondents stated high medication costs as the top challenge. 

Disjointed experiences for patients with complex conditions and the prevalence of polypharmacy further complicate specialty drug management. Identifying effective, cost-efficient treatments becomes challenging for overburdened providers. 

Several trends in the specialty space are worth noting as medications continue to consume a greater share of overall drug usage.  

As Peter Demogenes, vice president of Optum Health, explained to PharmaNewsIntelligence, "More medications being covered makes it difficult for payers and providers to manage specialty drugs and their costs most effectively." 

In response to these challenges, healthcare organizations are implementing innovative solutions. Optum's Specialty Fusion platform aims to integrate specialty drug management across medical and pharmacy benefits, offering faster approvals and a 17% cost reduction. 

Various strategies, including mail-order pharmacies and step therapy, help manage specialty pharmacy costs. Hospital administrations, often contributing to high costs, can be mitigated by administering specialty drugs in physician offices or patients' homes. 

Medication synchronization programs ensure continuous care, preventing disruptions and reinforcing adherence. Flexible programs are essential for managing specialty spending, delivering enhanced experiences, and curbing increasing costs. 

Innovative Solutions to Overcome Challenges 

To combat these challenges, healthcare organizations are implementing innovative solutions. Optum recently implemented its Specialty Fusion platform to eliminate the burden of managing specialty medications separately across the medical and pharmacy benefits. The platform provides specialty care for patients with complex conditions and lowers specialty drug costs. 

Patients can experience faster treatment approvals, reducing total cost savings. 

"Instead of simply moving costs from one benefit to another, Specialty Fusion reduces costs by optimizing value drivers," Demogenes stated. "The tool reviews all possible scenarios for the appropriate medications in the patient's treatment to analyze all attributes which could contribute to the cost of the medication." 

On the other hand, health plans and pharmacy benefit managers (PBMs) use various strategies to manage specialty pharmacy costs for employers, including hiking up copayments, limiting prescription durations, requiring mail-order pharmacies, and using step therapy. 

Mail-order medications are often less expensive and operate through a patient's health plan. Buying medicines in large quantities directly from drug manufacturers helps lower overall costs for patients. Additionally, step therapy is vital because it requires patients to try less expensive drugs before more expensive ones become an option. 

Adequate cost controls, such as CVS Health's Specialty Guideline Management and Advanced Control Specialty Formulary, help ensure that patients are prescribed the appropriate, low-cost therapy from the very beginning. Specifically, the company's solutions have helped patients save more than an average of 15%. 

Another notable player in high costs is hospital administration. Hospitals charge more for specialty drugs and their administration than independent physician offices, whether treatment occurs in a hospital or a hospital-owned physician practice. 

According to data from UnitedHealth Group, administering speciality drugs in physician offices and patients' homes instead of hospital outpatient settings for the five conditions that contribute to over 75% of spending on administered drugs can reduce costs by $16,000–37,000 per patient annually. 

This strategy reflects an overall savings opportunity of $4 billion annually. 

Lastly, medication synchronization for specialty drug management is vital because it ensures continuous prescription care, prevents interruptions in medication routine, and allows patients to adhere to their dosages. Standard components of medication synchronization programs, such as refill reminders and regular pharmacist appointments, help maintain synchronization and reinforce adherence behaviors over time. 

For example, Publix Super Markets rolled out its medication synchronization program in 2013. The program leverages an appointment-based model of medication synchronization in which appointment reminders and access to pharmacists are core components in addition to the synchronization itself. 

The program is available at no cost to anyone looking to enroll. It also offers monthly appointments with pharmacy staff members and a suite of monthly reminders to reinforce adherence. 

"The organizations that are best equipped have flexible programs in place to manage specialty spending best, deliver enhanced consumer and provider experiences, and drive down increasing costs," Demogenes said. 

"As we continue to see an influx of new expensive specialty drugs in the market, a solution to manage this spending is desperately needed. Managing specialty drug costs is more critical than ever, and the earlier factors create the need for an innovative solution to better manage specialty drug spending for clients and members," he concluded. 

As the market experiences a surge in expensive specialty drugs, an urgent need exists for innovative solutions to manage spending. Effectively navigating the evolving landscape of specialty drug challenges is critical for clients, members, and the healthcare industry.