Specialty Pharmacy: How Effective Teamwork Enhances the Patient Journey
Author: Jacqueline Hanna, PharmD, MSPBA, CSP
Whether it is a first-time fill or a refill, getting a patient their specialty medication requires a coordination of efforts across many internal departments of a specialty pharmacy and, at times, can even extend beyond the reach of the physical walls of a pharmacy. Each member of the specialty pharmacy care team is an essential component to not only delivering appropriate and efficient service but perhaps, more importantly, influencing and ensuring positive outcomes of therapy.
As no two patients’ needs are ever the same, each player in the specialty pharmacy care team provides invaluable expertise that directly contributes to the patient journey. It is with these varying sets of expertise that specialty pharmacy service can be customized to meet the unique needs of each and every patient and maximize their treatment experience.
While harnessing the talents and skills of each individual on our care team, working together and across channels promotes a culture that is patient-focused. By putting the team first instead of the individual, we can use our associates to their fullest potential to ensure every patient gets the attention that they need most.
Addressing Individual Patient Needs
Patients can face a variety of issues upon their first filling of a specialty medication. Additionally, once started on a specialty medication, patients may encounter many hurdles along the way that prevent medication persistence and impede their chances of remaining on therapy.
Whether these barriers are due to financial constraints, accessibility, adverse effects, lack of understanding of the medication or disease state, or issues affecting adherence, staying on therapy can be equally, if not more challenging, than initiating a new medication. Although some obstacles are more complex than others, as the prescription and the patient pass through the phases of filling and dispensing a medication, by assessing the unique needs of each patient, the right care team members can intervene at the right time.
Meet Your Specialty Pharmacy Care Team
Intake/data entry specialists
In the early stages of filling a new medication, the primary goal should be getting the medication to the patient as quickly as possible. Access can be one of the most complicated steps preventing a patient from getting started on therapy.
Intake and data entry specialists play a critical role in starting the specialty pharmacy filling process. Upon receiving the order, the pharmacy must determine whether or not they have access to the medication. If the medication is considered an exclusive or limited distribution medication, the intake process should account for quickly determining whether or not the pharmacy is able to fill the medication.
If the pharmacy is not contracted to fill, intake and data entry specialists are responsible for appropriately triaging the order to the correct pharmacy and communicating this to the patient. If the pharmacy is able to service the patient, intake and data entry specialists need to determine whether the documentation received is complete or is still missing key pieces of information before completing a new referral.
Once all documentation and patient information has been obtained, the referral can be completed, the patient is enrolled in the system and the order can begin progressing through the specialty pharmacy process.
Benefits investigation associates
Soon after receiving a new prescription, the benefits investigation commences. Benefits investigation team members must work with a sense of urgency regarding coverage of the medication.
Does the patient have insurance? Is the pharmacy in-network? Is the medication covered and, if so, is it under the prescription or medical benefit? Does the prescription require prior authorization (PA) or further documentation from the provider office? Does the patient have a copay or deductible and is the member eligible for manufacturer copay assistance?
Coverage determination can often become a rate-limiting step regarding the patient’s prescription being filled in a timely manner. Benefits investigation associates work tirelessly to obtain the appropriate benefit information by performing outreach to providers, insurers, and patients alike.
Once benefits are confirmed, the prescription can be properly processed or adjudicated and the patient’s out of pocket expenses can be assessed and the specialty pharmacy workflow can continue. Even after insurance has been established for a patient or if a patient requires a different medication at another point in time, benefits investigation expertise may be called on again.
For refill patients, benefits investigation associates play an integral role in ascertaining any changes to insurance coverage and the renewal of PAs.
In addition to performing typical duties, such as prescription entry and filling/labeling medications for dispensing, pharmacy technicians have expanded roles in specialty pharmacy. Depending on state laws, these additional duties may include outreach for prescription renewals, obtaining information regarding prescription clarification, and performing non-sterile and sterile compounding of various dermatological preparations, intravenous solutions, and infusions.
The role of pharmacy technicians can have direct and indirect implications on the specialty patient’s journey. In some instances, pharmacy technicians may have direct contact with patients and providers and assist with aspects of PA.
In other duties, the pharmacy technician’s role provides additional support to pharmacists, such as ensuring that all necessary supplies are entered along with the medication. Their attention to detail allows pharmacists to focus on clinical tasks and spend more one-on-one time with patients, once again shifting the focus to patient care.
Financial assistance professionals
Let’s face it, specialty pharmacy medications are expensive. Financial constraints are one of the most significant barriers to medication access and adherence. Even if a patient has insurance coverage, it does not necessarily mean that they will be able to afford the medication.
Out-of-pocket costs may arise due to a patient’s deductible or copay. Although some manufacturers may offer rebate programs and copay cards that can assist with out-of-pocket costs, patients with government-funded insurance plans, such as Medicare and Medicaid, are not eligible to participate and might need to look for other options for assistance.
Financial assistance professionals in specialty pharmacy can provide much needed service and guidance to patients who indicate financial hardship. Needs-based programs might be sponsored through the manufacturer, such as patient assistance programs, or available through other nonprofit foundations and grants.
After discussing a patient’s financial needs, the financial assistance professional can help to identify which programs the patient may be eligible for and what documentation is required. Having a hand in what can be an intimidating and arduous process, financial assistance professionals take some of this burden off of patients.
By finding ways to make medication more affordable, the patient has a better chance of starting and staying on therapy.
In traditional nursing roles, nurses provide direct medical education to patients and year after year are rated among the most trusted professions in the United States. Their training extends beyond the prescriber’s office and hospital setting and can greatly enhance the clinical management of patients in specialty pharmacy.
In-house nursing professionals can assist in performing disease state education, administration and injection training, home infusion coordination, and conduct patient assessments regarding medication use, adverse effects, and current lab values. Field nurses can add another layer of hands-on support to patients who are grappling with complex disease states.
Whether the pharmacy provides field nurses or outsources these additional services, home visits may be required to dispense certain limited distribution medications. Field nurses can provide in-person instruction or first dose administration while also capturing a patient’s vital signs. Nurses are a trusted resource for specialty patients, lending motivation and support when faced with a disease state that seems overwhelming to manage.
Specialty pharmacists are trained experts in the complex drug therapy regimens dispensed by specialty pharmacy. Management of specialty disease states such as oncology, inflammatory conditions, transplant, and infectious diseases such as hepatitis C and HIV requires close involvement with patients and providers.
The specialty pharmacist fulfills a variety of duties and not only plays an important role in providing clinical expertise but can also help to make sure that all the other players are participating and communicating. Collaboration of care is vital and the pharmacist facilitates this by having direct contact with both the patient and the prescriber, as well as other team members.
Pharmacists provide drug and disease state education to patients, assess the appropriateness of therapy and the need for ongoing therapy, and perform other clinical evaluations, such as drug utilization review. Through these tasks, pharmacists are able to help patients mitigate potential adverse effects, avoid contraindications and duplications in therapy, circumvent allergic reactions and drug-drug interactions, and ensure overall patient safety.
Additionally, pharmacist-patient counseling can address adherence issues early on and set the stage for positive outcomes while championing patients’ successes.
Customer service representatives
The specialty pharmacy customer service representative is on the front lines on a daily basis. Often times, customer service representatives are the first and the last members of the care team to interact with the patient.
Customer service representatives perform an array of tasks, including onboarding of a patient, inputting allergy information and medication lists, completing clinical questionnaires with the patient or caregiver, and scheduling a patient’s order for delivery.
In addition to patient-related tasks, customer service representatives also field incoming calls from patients, prescribers, insurance companies, and other pharmacies, and triaging them to the appropriate team members. Courtesy and attention to detail are invaluable skillsets in this role and help to improve turnaround times and coordination of efforts throughout the rest of the specialty pharmacy, providing excellent service to our patients and their providers.
It Takes Teamwork to Make the Dream Work
When everyone is working together and in the best interest of the patient, the specialty pharmacy team is setting them up for success. All members of the specialty pharmacy care team should be appreciated and used for the distinctive role that they each play in supporting the patient.
In specialty pharmacy, we should emphasize the “I’s” that it takes to create a comprehensive and collaborative care team. It is with this specialization and teamwork that our specialty pharmacies evolve into much more than just a place that patients obtain medications.
Instead, we shift to a patient-centric model and with our help, patients don’t have to attempt the journey alone.
About the Author
Jacqueline Hanna earned her Bachelor of Science in Biological Sciences from the University of Pittsburgh before earning her Doctor of Pharmacy degree from Duquesne University in 2011. She recently received her Master of Science in Pharmacy Business Administration (MSPBA) program at the University of Pittsburgh, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines. Jacqueline has spent the last 4 years working in Specialty Pharmacy, initially as a clinical pharmacist and most recently working on a variety of high-profile Specialty Operations Projects. In her current role, she is able to channel her passion for patient care into innovation and process design while being part of a concerted effort to transform Specialty Operations and improve the patient experience.