Retailers bolster specialty pharmacy capabilities as its role in the industry grows
As far back as the late 1970s, when patients were diagnosed with a complex chronic or rare condition and prescribed a specialty medication, specialty pharmacy was not in most retailers’ lexicon.
Yet, there were a handful of retailers who had the foresight to initiate care for these patients from the moment they received a diagnosis and were prescribed specialty medicine. Undeterred by the daunting task of providing in-depth monitoring and patient counseling, as well as reimbursement assistance, many of these retailers nonetheless delved into the specialty market.
The potential benefits of entering this market include the ability to enhance pharmacist-patient relationships to improve health, as well as ratcheting up their bottom line in a market that has experienced substantial growth in recent years.
In fact, although traditional growth in the retail channel is currently outpacing specialty growth with the help of COVID and flu vaccines and has 84% of total spend, Doug Long, IQVIA vice president of industry relations, said May 2021 data showed that specialty spend did increase 3.2% versus traditional, which grew at 4.2%.
Specialty Service Model
Prime standouts that have created successful specialty models include Walgreens, CVS Health, Rite Aid and Thrifty White.
CVS Health’s success in specialty pharmacy sheds light on the opportunities and challenges for retailers that serve specialty patients.
CVS Specialty began providing specialty medication services in 1978, with the launch of hemophilia home care.
“That service has since grown to being one of the nation’s largest hemophilia home therapy providers as a result of our strong relationships with hemophilia treatment centers, clinicians and individuals with hemophilia and their families,” said Prem Shah, CVS Health executive vice president, specialty and product innovation.
[Read More: Retailers build out their specialty pharmacy offerings]
Following the launch of hemophilia services, CVS Specialty successfully expanded its portfolio of therapies to include a wide range of chronic and genetic disorders, in addition to growing distribution of specialty medications through its network of specialty pharmacies.
Since 2013, CVS Caremark has acquired several businesses, including Coram and Novologix, to expand its specialty capabilities, as well as the services that support clients and their plan members.
“Novologix enhanced our ability to help clients and their members better manage their specialty medications and related costs,” Shah said.
Shah noted that CVS Specialty dispenses prescriptions to 1.3 million patients per year and provides home infusion services to more than 50,000 patients, as well as enteral nutrition to more than 20,000 members each month. Coram has 82 infusion locations nationwide, as well as 66 ambulatory infusion suites.
Plymouth, Minn.-based Thrifty White, which began early on to recognize and address the unmet needs for specialty services, continues to be successful in that area. In the 1990s, the Midwest chain began dispensing specialty pharmacy products and, in 2014, built out a dedicated central team to support specialty patients. It also obtained URAC and ACHC accreditation.
Jeremy Faulks, director of specialty pharmacy and procurement, said that by taking an active approach to specialty that focuses on a one-to-one relationship between its pharmacists and patients, the chain has quadrupled the number of its specialty patients.
“Thrifty White’s core specialty offering has always been about offering a better experience to both our patients and our provider groups,” Faulks said. “Our offering focuses on providing the best central expertise and service, but also a local, face-to-face counseling and education experience.”
To this end, Thrifty White has trained more than 100 of its community pharmacists in key specialty clinical and counseling components, and it offers Specialty Center of Excellences at all of its local pharmacies. The range of chronic conditions that the chain treats includes psoriasis, atopic dermatitis, Crohn’s disease/colitis, GI, rheumatology, behavioral health, oncology, HIV, MS and asthma.
“One of our key initiatives included training our pharmacists to provide medication injection services, so we can continue to advance the practice of pharmacy while also facilitating the patient-pharmacist relationship,” Faulks said. “So much specialty is dispensed via mail these days, it’s refreshing for our patients and providers to receive more comprehensive service in their local community.”
Walgreens also stands out for its success in specialty pharmacy. The chain made a foray into community- based specialty pharmacy in the late 1990s at the Howard Brown Health Center in Chicago.
“We were supporting the care team as the HIV and AIDS epidemic was ravaging the community there,” said Alexandra Broadus, Walgreens senior director of specialty health solutions. “We became involved when there was no such thing as a specialty pharmacy. We have always prioritized supporting patients in our communities with all of their conditions, including specialized and complex conditions.”
In the early 2000s, Walgreens’ expansion into specialty was marked by its purchase of Schraft’s pharmacy, which specializes in fertility. Broadus noted that this was Walgreens’ first central specialty pharmacy.
The acquisition of Medmark Specialty Pharmacy and Cystic Fibrosis Services Pharmacy, and a joint venture with Prime to create AllianceRx Walgreens Prime followed. Today, Walgreens has over 300 community-based specialty pharmacies that are URAC accredited. In addition to traditional Walgreens pharmacies, these specialty locations support a range of conditions, including HIV and cancers.
“We care for over 8 million Americans daily,” Broadus said. “We want to be there for them on their entire journey from when they first step into our pharmacy for first line therapy to when their treatment may become more complex and have other needs.”
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Fertility is yet another area that Walgreens specialty concentrates on.
“Within the fertility space, an increasing number of employers in more states are mandating fertility coverage,” Broadus said. “It’s one of the most emotionally trying times for many people. It’s not just for patients experiencing infertility, but also for LGBTQ families as part of their family planning journey, and patients with cancer who need fertility preservation services. We are deeply committed to it.”
Rite Aid also is making its mark in the specialty space and addressing gaps in access to specialty services. In 2015, Rite Aid acquired Elixir Pharmacy, a pharmacy benefit manager that also has its own specialty pharmacy, Elixir Specialty.
Don Gale, senior vice president of Elixir Pharmacy, said that Elixir Specialty has grown its portfolio to nearly $100 million in annual revenue in 2020.
Elixir Specialty has developed medication-and customer-specific clinical protocols within the following therapeutic areas: cardiovascular; growth hormone; hematology (anemia, hemophilia, neutropenia, thrombocytopenia); hepatitis C; HIV; immune globulin; inflammatory conditions (ankylosing spondylitis, atopic dermatitis, Crohn’s disease, hidradenitis suppurativa, juvenile arthritis, lupus, psoriasis, psoriatic arthritis, rheumatoid arthritis, ulcerative colitis, uticaria and uveitis); multiple sclerosis; oncology; and pulmonary conditions, including allergic asthma, idiopathic pulmonary fibrosis, nasal polyps and pulmonary hypertension.
Partnerships and Collaborations
As retailers treat patients with a wide range of chronic conditions, they also are finding that collaborations with advocacy groups are crucial. Walgreens’ collaborations in the oncology area are a case in point. The chain has worked with the Look Good Feel Better Foundation and various cancer support communities to launch its Feel More Like You service, which has Walgreens’ beauty consultants trained to help cancer patients better manage their side effects that may be visible from their treatment, as well as provide the confidence and support they and their caregivers need.
“Our patients might visit one of our community-based specialty pharmacies, but they often go to their traditional Walgreens on the corner for their other needs,” Broadus said. “We create this connection between our pharmacists and beauty consultants to bring care together for them, making sure they are supported throughout their journey.”
Walgreens also collaborates with the Susan G. Komen Breast Cancer Foundation, and through the Walgreens Find Care platform, the chain connects patients to cancer screenings. “We help patients through that moment of diagnosis as they start therapy, and if they are able to finish with treatment, help them transition to a different routine, as well as through survivorship,” Broadus said.
For patients who visit their local Walgreens pharmacy, the chain offers clinical programs and other wraparound services, including patient assistance.
“If they choose to use one of Walgreens’ 300 community-based specialty locations that are URAC accredited, they receive care from team members with specialized training in breast and blood cancers,” Broadus said. “If patients prefer to use their local Walgreens or our centralized specialty asset through AllianceRx Walgreens Prime, they can while receiving the same level of care.”
Walgreens’ partnership with VillageMD also is beneficial to specialty patients. “We’re doing a lot of great work to make sure pharmacists are integrated into the primary care team and care model and helping patients,” Broadus said.
CVS Specialty also boasts a range of collaborations that it has with patient advocacy and support groups that are focused on education, awareness, improving access to testing, screening, healthcare services and health equity. These partnerships include the Arthritis Foundation, American Cancer Society, American Heart Association, American Diabetes Association, PAH Foundation, PHAware, National Hemophilia Foundation and the MS Society.
Affordability in Focus
Beyond partnerships and collaborations with advocacy groups and others, helping patients afford specialty medications, which can cost up to $6,000 a year, is yet another crucial responsibility for retailers in the specialty arena, and it requires a knowledgeable staff and the development of cost-saving resources for patients.
Elixir Specialty takes financial assistance for patients to the highest level. “We also find it rewarding that we link 97% of our eligible customer population to financial assistance to ensure they can overcome any financial barriers to therapy that they face,” Gale said.
Thrifty White is not sitting on the sidelines when it comes to helping patients afford their medications. The chain works closely with its manufacturer and payer partners to create programs to support their products/members.
Faulks explained that Thrifty White has joined major health plans, including BlueCross BlueShield Minnesota and North Dakota, and HealthPartners, to make medications available locally for their members.
Offering prior authorization support as a way to mitigate declines in patients starting therapy, adding new medications or staying on therapy also is paramount to success in specialty pharmacy.
[Read More: AllianceRx Walgreens Prime earns URAC reaccreditation for home delivery pharmacy]
Establishing EHR data connections to collect information needed to facilitate prior authorization data gathering and submission is an example of helping patients starting therapy quickly on the most appropriate treatment, CVS Health’s Shah said. “Supporting initiation of treatment and therapy continuity are essential for optimal adherence and care of those with complex health conditions.”
CVS Specialty takes this responsibility seriously and its initiatives in this area are paying off. “We can see the electronic health records for almost 70% of our specialty patients,” Shah said. “Our proprietary Novologix technology offers online, real-time access to an automated prior authorization process across the medical and pharmacy benefits with a single front-end system. Providers can enter the request in one place, the automated system guides the request to appropriate benefit and simplifies the process for prescribers and their office staff.”
The platform also integrates National Comprehensive Cancer Network Clinical Guidelines and offers multi-regimen level authorization for treatments aligned to evidence-based guidelines.
Overcoming Restrictions
Aside from addressing the challenge of providing support with prior authorization, retailers also must overcome payer and manufacturer restrictions since many specialty drugs are available only from limited distribution networks.
“The biggest challenges in specialty are due to payer and manufacturer restrictions,” Faulks said. “With the competition for these patients, it’s an ongoing effort to ensure we have access to patients. If you can convince your local health plans, employers and providers to keep you in the network, the benefits to patients are huge.”
Walgreens’ Broadus emphasized that to address specialty medications that have limited drug distribution networks, the chain has a dedicated team that looks at these prescriptions and figures out where a patient can get the medication, even if it is from a competitor.
“Can they use one of our 300 local solutions or AllianceRx Walgreens Prime to receive care, or do they need to use a different specialty pharmacy?” Broadus said. “Our teams will seamlessly get that prescription where it needs to go, whether that’s within Walgreens or one of our competitors. Our primary mandate is to make sure we are taking care of that patient.”
To ensure that patients obtain their medications, Elixir Specialty has partnered with 31 manufacturers in its limited distribution drug program, Gale noted.
Patient Adherence
Once patients get their medications, ensuring they are adherent with their regimen and don’t suffer from any potential side effects are yet another responsibility that retailers must assume if they want to be successful in specialty pharmacy.
Elixir Specialty’s clinical staff, on average, engages with its customers for 25 minutes of consultation prior to starting their therapy to review dosing, administration, how to manage side effects if they are present, medication storage and to address patients’ questions, Gale said.
CVS Specialty’s Transform Oncology Care program opens a window on improving patients’ adherence with their specialty drugs.
“The program helps improve outcomes and experience while lowering costs for patients, providers and payers by enabling the best, right treatment at the right time, driving for the best quality care at the best value,” Shah said. “It also gives members the best chance to succeed in their cancer journey with proactive outreach, earlier and more often.”
The program incorporates care management with a focus on care coordination, post-acute and palliative care, as well as adherence support for members on orals. “It utilizes our accessible, local footprint, connected data and integrated systems to help better identify and intervene with patients who could benefit from preventive or screening services,” Shah said.
Yet another medication adherence strategy that CVS Specialty has instituted is having its CareTeams, made up of specially trained pharmacists and nurses who collaborate and intervene in member care on multiple levels, conduct initial assessments, symptom tracking with guided care recommendations, ongoing clinical assessments, medication reconciliation, intervention assessments if appropriate, clinical reassessment post intervention and the use of digital tools.
Thrifty White also has put in place measures to increase medication adherence. “On the manufacturer side, we run multiple clinical programs focused on reducing primary nonadherence, increasing patient persistency on therapy and managing side effect issues,” Faulks said.
The chain also offers clinical counseling, face-to-face medication administration and device training. “From paying for the drug, managing and mitigating side effects, and promoting adherence, patients truly benefit from the additional level of care,” Faulks said.
Walgreens is no stranger to offering solutions to increase patient adherence. Its Connected Care program uses a patient-centered process to improve patient outcomes. “The technology helps guide interactions with patients, helping them stay on their treatment and manage any possible side effects,” Broadus said.
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Pandemic Impact
Despite all of their efforts to excel at specialty, the pandemic has had a tremendous impact on specialty pharmacies’ ability to provide face-to-face patient care. Still chains rose to the occasion.
“The pandemic definitely taught us to be more flexible in how we deliver care,” Faulks said. “From developing remote models, drive-thru and curbside pickup, our pharmacies remained open and accessible to patients throughout the pandemic. Even in the early days when many clinics closed, our specialty patients could still visit the pharmacy, get trained on their medication or get an injection from our pharmacist. This access to care was a huge win and a great example of how important the community pharmacy setting is.”
Walgreens also served patients when shut downs were in place. “All in all, we stayed open and provided support to patients throughout the pandemic, as well as during various natural disasters. Because we’re locally based, we’re able to support our patients through it all,” Broadus said.
CVS Specialty also remained focused on ensuring that members had access to specialty medications amid the pandemic. “We were prepared with digital tools, engaged patients, connected clinicians, consistent messaging across channels and ready access via digital or phone to ensure patients had access to expert clinical staff to answer questions and support healthcare needs,” Shah said.
Elixir Specialty also reacted to the pandemic without flinching. Gale said that its customers maintained their overall adherence rate to their medication regimen of greater than 90% throughout the pandemic.
“While the pandemic has challenged many traditional social interactions, pharmacists have been developing customer relationships beyond the counter since the inception of specialty pharmacy,” Gale said. “The pandemic has highlighted that the remote model of pharmacy in place at Elixir Specialty works and is well prepared for emergency situations like a pandemic. In 2020, we saw an increase in customer interaction while doctor offices remained closed or accepted only limited appointments. We feel that our model was key in providing the exceptional clinical support that our customers have come to expect while continuing to deliver medications on time for the customer.”
The Future of Specialty
Broadus said Walgreens expects to expand HIV testing, which it now offers in select stores, as part of the chain’s broader health testing strategy.
“We’ve already seen what pharmacists can do in light of COVID, imagine the impact that pharmacists can have on helping patients who may be at risk of HIV access care and get on to PrEP?” she said. “We have the privilege of being in so many communities, how can we leverage our pharmacists to help patients get the care they need?”
Faulks envisioned that Thrifty White’s continued growth in specialty will include working closer with its health system providers, expanding disease states and geographic territory, and the chain looking at how it can expand specialty services to traditionally non-specialty products, such as diabetes.
Shah said the future that CVS Specialty sees will entail using sensor data to trigger additional meaningful interventions for oncology and RA activity, using a payer agnostic approach to integrate wearables and digital devices for increased remote monitoring that can be shared simultaneously with the member and their care providers.
He also projected that the future will involve an effort to accelerate proven data science techniques to prompt clinical interventions to additional therapies and conditions based on various data inputs, as well as a push to expand patient-reported outcome assessment, patient reported outcomes and symptom tracker tools based on proven success in oncology.
CVS Specialty’s road map features multidisciplinary solutions and technology for rheumatoid arthritis, inflammatory bowel disease, Crohn’s disease, psoriasis, cystic fibrosis, hereditary angioedema, multiple sclerosis and hemophilia, as well as a kidney care program with new technology for in-home hemodialysis.
Gale projected that Elixir Specialty will continue to seek out partnerships with manufacturers in the growing limited distribution drug market. “We also continue to seek out opportunities to support health plans in the market by participating in their pharmacy networks,” he said.
Enhanced services being considered include Elixir Specialty and Rite Aid retail pharmacy service support for contingency and urgent specialty fills with easy-to-access points of contact, improvements to the member experience with Rite Aid local pickup option with Elixir Specialty, and specialty case management services offered to members filling in a retail location, Gale noted.
Perhaps Gale summed up the future best for retailers in the specialty space: “Specialty conditions can be very complex, have a significant impact to quality of life, involve multiple high cost treatments — which may require special storage, handling and administration — and create unique challenges to medication adherence and optimal clinical outcomes,” he said. “Specialty pharmacies and pharmacists are positioned to have the greatest impact in combating these challenges by partnering with customers to promote health and happiness.”