All of the stakeholders agree that patient outcomes is a priority. Why do we allow fragmented patient care, payments, and delivery systems?
Possibly the most important innovation in automobile safety was the “Crumple Zone” invented by Mercedes-Benz. They went on with Bosch to develop the second-generation anti-lock braking system (ABS), another milestone in safety. Mercedes continued safety firsts with the “Electronic Stability Program” and “Brake Assist.”
The company that invented many of the significant automotive safety features never fought to keep them exclusive but instead licensed them so that they would be widely implemented and ultimately become standard equipment in many automobiles today. What a novel idea—invent something great and make it the industry standard for the greater good of all.
I cannot help but wonder why we do not take this same approach in health care, specifically in specialty pharmacy? All the stakeholders agree that patient outcomes are the priority. The question becomes why do we allow fragmented patient care, payments, and delivery systems? Why are there restricted networks, mandatory mail, and limited distributed medications for the sickest patients needing the most services?
Specialty medications pose a series of challenges for patients, including cost, access, prior authorizations, safety, storage, stability, counseling and support, and compliance. “Specialty Pharmacy” arose from independent providers who offered solutions and services for these challenges. Specialty providers have evolved over the years and technology has helped them become more efficient in providing care and collecting data.
As these medications continue to drive the growth of the pharmaceutical industry and the overall cost of health care, the landscape has changed. Payers and managed care organizations have been told that the only way to control cost is to have a restricted network. Pharmacy benefit managers (PBMs) have positioned themselves to exploit specialty medications and capture more business. How can you provide a check and balance on behalf of payers when your own company is executing the transactions?
Another factor that has changed is the increase in the controlled distribution system. Although a limited distribution network makes sense from a manufacturer’s perspective in controlling inventory, using data to predict manufacturing needs and defining prescribing patterns to help forecast demand. The hub system, although wonderful in theory and having some great potential, is not the solution for physicians’ offices and patients. Can you imagine one day going to your specialist and having them prescribe 3 medications that require special forms and possibly having 3 different specialty providers contacting you about each medication separately? How does this help with collaborating to provide the best possible outcomes for our patients?
There are 2 lingering factors in the Affordable Care Act that can impact our industry. The first calls for PBMs that participate in state insurance exchanges to disclose detailed information on their pricing mechanisms and savings rates. This should be eyeopening for payers who were promised savings. The second and more exciting is the establishment of Accountable Care Organizations (ACOs) which encourages hospitals, physicians, and other providers to improve the quality of care and reduce overall costs through a collaborative approach. By using this collaborative and sharing approach, CMS will be able to compare different ACOs and determine best practices.
In this setting, can you imagine if we took the Mercedes approach and used the best practices as industry standards in our health care system? This would truly be revolutionary if all the stakeholders could agree on 1 specific protocol for specialty patients based on their disease-specific underlining conditions. There would be no need for restricting patient or physician access, no need for mandatory mail, a true savings for payers, and the ultimate goal of improving patient care and outcomes would be met! SPT
About the Author
Nicholas Karalis, RPh, is a specialty pharmacist and co-owner of Elwyn Specialty Care, which offers specialty pharmacy services in HIV, oncology, hepatitis C, multiple sclerosis, rheumatoid arthritis, Crohn’s disease, psoriasis, and other areas. A leading voice in community pharmacy, he is a founding member and board member of the Community Specialty Pharmacy Network (CSPN), as well as a board member of the Cardinal Health National Home Health Care Advisory Board. Mr. Karalis is an editorial board member of
Specialty Pharmacy Times.