Richard Harris, MD
The use of specialty pharmacy in oncology practice has grown, becoming a mainstay for many practices. Historically, that has not been the case for urology practices, but that trend is changing as more urologists see the potential of managing their prostate cancer patients with oral oncolytics, rather than referring them immediately to medical oncologists. There are many processes for a urology practice to consider when partnering with a specialty pharmacy, including time and capital investments. Challenges include prior authorization, storage of medications, adherence, and benefits investigations.
“I think it’s a newer trend in actually a number of clinical specialties and urology would certainly be one of them,” said Richard Demers, RPh, MS, assistant executive hospital director for pharmacy services at the University of Pennsylvania. “The term specialty pharmacy defines a market space of products that have a significant per dose or per month expense associated with them. They also often require prior authorization from payers in order to be covered.”
Eric Sredzinski, PharmD, concurs. “I would say urology and specialty pharmacy are at a crossroads at this point.” With the approvals of medications for advanced prostate cancer, such as abiraterone acetate (Zytiga) or enzalutamide (Xtandi) “we are starting to see more urology practices working with specialty pharmacy,” said Sredzinski, an executive vice president of Clinical Affairs and Quality Assurance for Avella Specialty Pharmacy.
The trend is growing for a number of reasons, including the need for increased patient support from a prior authorization perspective or a narrow distribution network for particular agents. Although abiraterone and enzalutamide have limited distributed, “some agents have closed distribution channels so there are very few people who can purchase those products,” said Demers.
Eric Sredzinski, PharmD
Additionally, “manufacturers have implemented processes to direct these prescriptions through a centralized hub,” said Sredzinski. “In our case, we have a specific team dedicated to urology. We have streamlined the process so that we can work with the office conducting the benefits investigation to determine where the coverage lies for that prescription.”
When a practice is considering seeking a relationship with a specialty pharmacy, the first step is to understand how the practice is currently configured. Sredzinski says the practice needs to ask how it currently manages their patients and who is involved. Who are the main points of contact within the organization? What outcomes do they want to achieve, and what kind of communication do they want from the specialty pharmacy?
Once those questions are answered, his company “seeks to provide an overlay on what the practice is currently providing and create enhanced services.” The practice manager should understand what the specialty pharmacy is doing during different time points—how the specialty pharmacy is providing counseling, how the information is being provided to patients, and if any issues need to be escalated and addressed by the urologist. Any data or feedback should be provided back to the practice manager, who can then use it to improve patient outcomes.
Level of Complexity
Specialty pharmacy also adds a level of complexity to patient care, usually to the patient’s benefit. Specialty pharmacies are particularly adept at dealing with financial issues, exploration and explanation of member benefits, and providing patient support. Also, many specialty pharmacy medications require special storage facilities and processes. Specialty pharmacies can ensure the integrity of the agent through the distribution process, from the manufacturer, to storage, and to final delivery to the patient.
These requirements might be new to the urology practice staffers and the set of activities to handle specialty pharmacy medications could be beyond the scope of the staff’s experience.
“Because of the added activity that needs to occur around these therapies, as far as control and access and patient teaching, finding a good partner on the specialty side is probably very valuable to a urology practice,” said Demers.
In addition, specialty pharmacy is particularly focused on patient education and improving patient adherence, Sredzinski explains. “Our specialty pharmacy, for example, will call the patient at the initiation of therapy and then mid-cycle in their therapy regimen to make sure that the patient is adhering to their medications and if they have any issues, we’re helping to address them at that point in time.”
Acting at the Interface
Richard Demers, RPh, MS
Specialty pharmacy also gets involved in financial assistance, added Demers. Acting at the interface between the patient and the payer, specialty pharmacy ensures the patient can get access to the medications. Because of the high cost associated with these medications, there are a number of considerations, said Demers.
Some practices do not have the ability to dispense the product or to adjudicate the product through the insurer, so this is an added expense to the practice that is not accounted for by an additional revenue stream. “This is not reimbursable,” said Demers.
A big component of specialty pharmacy is navigating the landscape of insurance and the benefits for the patients, said Sredâ€¨zinski. “For instance, we would work with the urologist’s office to determine what insurance the patient has and what the coverage criteria looks like. Then, assist with the processing of prior authorization and ensure that the appropriate forms are used.
“There is the overall cost of the medication and whether the payer will in fact support paying for the medication in general. Typically many of the payers have a significant copayment associated with the product and those copayments can be quite substantial for the patient. Many specialty pharmacies, ours included, work with either drug companies or other sources to obtain funds to offset some of the copayment responsibility for patients,” said Sredzinski.
In this current environment in which high copayments and cost shifting becomes the patient’s responsibility, the patients’ financial exposure can be very high, said Sredzinski. Specialty pharmacy can work to explore and exhaust all avenues for copayment assistance, whether that is a copayment card that can be leveraged through commercial or private insurance, or working with a foundation that can provide copayment support. The end goal is to drive that copayment down to near zero. The last avenue would be working with the manufacturer to get free access to the drugs for patients who don’t qualify financially. “The specialty pharmacy is doing a lot of work on the front end to ensure the medication gets to the patient, which alleviates a lot of the work on the urology office.”
And that includes actual patient care. Specialty pharmacy discusses adverse drug event management, disease state management, and adherence programs. Many factors go into helping manage these drugs for these patients. “Many of the offices that we work with, even the oncology practices, don’t have the process and employees to ensure that the patients really get the optimal experience when being prescribed these drugs,” said Sredzinski.
Improving Practice Efficiencies
A strong specialty pharmacy can take on much of the financial evaluation and patient assistance duties, while improving practice efficiencies.
“Through the specialty pharmacy, the practice knows when the patients are ordering the drugs, when the patients are getting the drugs, and presumably that patients are taking the drugs. And physicians have a better handle to monitor the patients taking the medication,” said Richard Harris, MD, president and chief executive officer of UroPartners, an integrated practice of more than 55 experienced urological specialists, pathologists, and radiation oncologists.
By incorporating a specialty pharmacy, urologists can maintain that continuity of patient care. It is an advantage of many large groups, said Harris.
Successful integration of a specialty pharmacy into a urologic office depends on the volume of prescriptions. Office staff can spend long periods on the phone navigating the insurance process. “There can be a significant savings to the office and the redeployment of the staff to actually managing patients versus being on the phone” added Sredzinski.
Sredzinski is confident that “once the practice manager sees how seamless it is to work with a specialty pharmacy, the in-office drug dispensing model becomes more of an administrative burden.”
The benefits of working with a specialty pharmacy are numerous. Urology practices may see an opportunity to use specialty pharmacy in achieving the important goal of a successful outcome for the patient.