Facilitating complex care with specialty pharmacy protocols

Specialty pharmaceuticals are scientific marvels, improving the health and quality of life for millions of people. They’re also expensive. In fact, while just 5.5 percent of the US population is on specialty medications, they account for 50 percent of pharmacy spend.

That cost is a major pain point for patients, who often delay or skip care because they can’t afford it, which leads to worse health outcomes and could result in penalties for providers operating within a value-based care paradigm.

The good news: pharmacists can help improve adherence and health outcomes while keeping costs down by creating and adhering to specialty pharmacy protocols. And RxLive can facilitate that work. Here’s how.

The need for specialty pharmacy support

Before we dive into the solution, it’s worth taking a step back to understand the context of the problem.

We are currently experiencing a provider shortage across nearly every profession in healthcare. Primary care physicians are not exempt; in fact, they report levels of burnout as high as 70 percent, suggesting our shortage could get worse before it gets better.

In many areas (particularly rural parts of the country), primary care physicians are operating without access to adequate specialists (again, because of the shortage). They’re asked to provide specialty care without the additional fellowships and training specialists receive.

When that involves prescribing specialty medication, they are at a double disadvantage: not only are they not specialists in the disease state they’re treating, they’re not specialists in the pharmacotherapy involved in treating that disease.

When they do prescribe a specialty medication for a patient, for example, the patient may not be able to start treatment until the insurer establishes prior authorization, or certification of medical necessity – a process that can take weeks and requires even more of the physician’s time. Or maybe the pharmacist is unable to fill a prescription because they don’t have essential information on file for the patient – liver function numbers, for example, or proof of a recent negative TB (tuberculosis) test. 

A clinical pharmacist working with established specialty pharmacy protocols can alleviate these problems and streamline patient care. Let’s take a look at how.

How specialty pharmacy leads to faster, more cost-effective care

One of the most important roles a specialty pharmacist can serve is to identify lower-cost alternatives for specialty medications. Insurers often require prior authorization for costly and newer specialty medicines, but that’s not only a cost-saving measure.

Step therapy is a commonsense approach to treating any number of conditions, as it prioritizes trying established, lower-cost drugs with often decades of safety data on the record.

So in the cases of a PCP prescribing a specialty medication, the pharmacist’s first move might be to suggest alternative therapies. In many cases, the patient will be able to start these treatments immediately – a win for everyone. If the patient does not respond adequately to first-line therapy, then a more costly specialty medication might be required. 

In cases where the pharmacist verifies that the specialty medication is the correct treatment path, they can establish protocols for ensuring prescriptions get filled in a timely manner. For example…

  • Asking physicians to include supplemental information in prescriptions. Even if the e-prescribe form doesn’t have a dedicated space to indicate a recent normal liver function test, for example, the pharmacist can ask that the physician include this information to prevent its absence from becoming a hiccup in filling the prescription.
  • Highlighting clinical dispensing requirements. Pharmacists can indicate whether, for a given medication, patients must have regular lab tests, which tests they must have, and what the acceptable ranges are. 
  • Managing comorbidities. As of 2018, 27.2 percent of Americans have multiple chronic health conditions. Managing them in tandem to acute illnesses is critical to positive health outcomes.

Specialty pharmacists can establish workflows for managing patient out-of-pocket costs (rebate programs, direct-from-manufacturer programs, biosimilars, etc.). When patients are eligible for additional assistance, the pharmacist can educate the patient, then hand off the completion of the form to the care coordination team, who can ensure all forms are completed and receive physician sign-off.

Today, RxLive makes all of this possible. Our My.RxLive tool pulls data from health information exchanges (HIEs) and electronic health records (EHRs) to quickly provide information about alternatives to specialty medications (when appropriate) and background health information required to fill specialty prescriptions.

Building a more streamlined future for specialty pharmacy

Until we resolve the provider shortage, we’ll need tools to empower the providers we have to make better, more effective decisions around specialty pharmaceuticals.

To support that, we’re building clinical decision support within My.RxLive, which will help guide PCPs tasked with treating patients who might be eligible for specialty medications.

Of course, that digital support is no replacement for fully trained specialty pharmacists. To that end, we’re building out our fractional network of pharmacists and investing in training for those already in our network so that more physicians can access the support of clinical pharmacists to improve patient safety, efficacy, and access to specialty medications.

Better protocols lead to better health outcomes

Specialty pharmacy protocols can play a big role in ensuring that people get safe, effective treatment in a timely manner, improving health outcomes across a variety of conditions.

And because of the high dollar cost of specialty medicines, even relatively modest improvements in efficiency can yield big savings for both patients and healthcare systems while improving disease outcomes.

For more information on how RxLive can support specialty medication prescribing in your network, get in touch. We’d love to provide more information.

Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.