It’s no secret that declining margins, low reimbursement, DIR fees, and the need to fill a higher volume of prescriptions in record time have, combined, become an Achilles’ heel for many pharmacy retailers. Less well-known are the retailers that have carved out a niche in specialty pharmacy and are sprinting forward and experiencing less pain than their retail brethren that have not yet stepped into this rapidly growing and profitable arena.
In fact, over the last 12 months, specialty is growing by 10% on a dollar basis, while traditional products are flat, according to IQVIA vice president of industry relations Doug Long. “Specialty now accounts for 49% of dollar sales,” Long said.
Retailers that delve into specialty have the potential to boost their bottom line, as well as the ability to accentuate their pharmacists’ relationships with patients to improve their health.
Prime examples are a handful of retailers that have created successful specialty models as Amber Specialty Pharmacy, a subsidiary of Hy-Vee; Thrifty White Specialty Pharmacy; and Publix Specialty Pharmacy.
Prior to 2010, Hy-Vee pharmacies were filling specialty prescriptions off-site for members of its employee benefit plan. When Hy-Vee saw opportunity in this space, the retailer embarked on a 50/50 joint venture with Omaha, Neb.-based Amber Pharmacy to create Hy-Vee Pharmacy Solutions, which served Hy-Vee’s employee benefit plan.
In 2014, after experiencing dramatic growth, the chain acquired the assets of Hy-Vee Pharmacy Solutions, as well as Amber Pharmacy. It is celebrating its rebranding as Amber Specialty Pharmacy in September.
“Since that time, we have invested a lot and grown dramatically to be able to take care of even more patients in the specialty pharmacy space. It’s definitely an up-and-coming area of pharmacy,” said Aaron Wiese, Hy-Vee’s senior vice president of health, wellness and business development, and president of Amber Specialty Pharmacy.
Amber, which is licensed in 50 states and Puerto Rico, has 20 specialty pharmacy locations throughout the United States, 10 of which opened in the last 12 months. Its locations span from Portland, Maine to Orlando, Fla.
Initially, Amber Pharmacy focused on immunosuppressants for organ transplants. That focus has swelled to encompass a wide range of such inflammatory conditions as Crohn’s disease, colitis and rheumatoid arthritis; multiple forms of cancer, including breast, prostate, blood cancer, leukemia and lymphoma; and neurological conditions, including multiple sclerosis, movement disorders and epilepsy.
Thrifty White also has experienced success in specialty pharmacy. The Midwest chain was filling specialty drugs at its retail pharmacy for many years, but six years ago, it started building a dedicated specialty site, with a dedicated team that oversees insurance processing, drug fulfillment, patient management and clinical counseling.
Jeremy Faulks, Thrifty White’s director of specialty pharmacy and pharmacy procurement, said that the company wanted to do something different and not become “just another mail order specialty pharmacy.”
Today, Thrifty White Specialty Pharmacy is licensed in 50 states and focuses on three areas: chronic inflammatory diseases, such as rheumatoid arthritis, Crohn’s disease, colitis, dermatology (psoriasis); oncology; and behavioral health.
“We have the ability to mail specialty medications nationwide, but 90% of what we do is picked up locally,” Faulks said. The remaining 10% of specialty drugs are delivered to patients who are unable to visit the pharmacy, or don’t live near a Thrifty White location.
With locations in many smaller towns and rural communities in Minnesota and North Dakota, having a specialty pharmacy enables Thrifty White to help patients who would not otherwise be served.
For example, there may be a cancer center in some of those areas that don’t have a pharmacy.
“They rely on us to be the key pharmacy to manage these oncology patients, especially with the growth of oral oncology medications,” Faulks said.
Publix’s success in specialty pharmacy also opens a window on the opportunities for retailers to serve patients in their communities.
Publix offered specialty medications for many years and took a more concerted approach when it opened the first Publix Pharmacy in 2012 at Moffitt Cancer Center, where it serves as the onsite outpatient pharmacy for the hospital. In 2013, Publix Pharmacy opened a closed-door pharmacy offering compounded and specialty medications.
Toan Do, Publix’s director of central and specialty pharmacy, said that in 2015, resources were dedicated to grow the specialty pharmacy department to provide the full suite of services specialty patients require.
Publix Specialty Pharmacy dispenses medications for cancer, rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, hemophilia, hepatitis C , HIV, multiple sclerosis and pituitary disorders. Publix’s approach to patients is evidence of the impact that retailers can have serving their pharmacy patients with specialty pharmacy.
“In general, patients do not know if the prescription they have is specialty or not, and we do not believe patients should shoulder that burden. Patients need to know that they have a prescription, and Publix is their pharmacy,” Do said. “We strive to meet patients’ prescription needs, while continuing to deliver the premier Publix service our customers know and love. Specialty patients can stop by any of our pharmacies, and we will help navigate the complex process of starting, adhering to and optimizing therapy on specialty medications in person.”
A Growing Roster
Pharmaceutical companies are instrumental in helping specialty pharmacies be successful. Indeed, new treatments for various diseases have been the key drivers of drug spend in specialty, and offering access is a big goal for many retailers. Though the boom that accompanied many hepatitis drugs in the mid-aughts has subsided somewhat, drug firms continue to expand their pipelines.
Among Upsher-Smith’s offerings, which include a large portfolio of generics and several branded medications to treat migraine and/or epilepsy, is Vigadrone (vigabatrin) for oral solution, a specialty drug for the treatment of infantile spasms and refractory complex partial seizures.
In addition to Vigadrone, Upsher-Smith’s branded products that may be sold through specialty and traditional pharmacy include Tosymra (sumatriptan nasal spray), Zembrace SymTouch (sumatriptan) injection, and Qudexy XR (topiramate) extended-release capsules.
As patents expire on older specialty medications, more generics companies are entering the specialty market, among them Aurobindo. The East Windsor, N.J.-based company launched its generic of Ancobon (flucytosine) capsules in June, adding the specialty antifungal product to its offerings. Paul McMahon, Aurobindo’s senior vice president of commercial operations, said the company expects Food and Drug Administration approval for additional specialty products.
“Aurobindo believes we can improve the health of specialty patients by bringing value-oriented products to market to address their needs,” McMahon said. “That is why it’s important for Aurobindo to continue to provide high quality niche specialty products for patients and also provide our customers with high quality customer service in all customer-related activities including orders, shipments and correspondence.”
Having a wide range of specialty drugs to prescribe is one thing, but getting patients started on specialty medications faster to successfully drive medication adherence and improve outcomes also is paramount, which is where many technology companies come into the picture.
Partnering for Success
“Biosimilar drug approvals increased significantly this past year. This means pharmacists have more choices and opportunities to examine how these new therapies can benefit patients,” said Marvin Richardson, CEO of Johnson City, N.Y.-based Innovation. “Pharmacy automation solutions from Innovation create the time a pharmacist needs to work with a healthcare team to ensure that patients have access to the right mix of medications that support the best possible outcome for the patient.”
Maximizing the time that pharmacists can spend counseling specialty patients is a critical part of any specialty offering because the drugs being dispensed require a high level of care, according to Publix’s Do.
Jill Regan, director of relationship management at Alpharetta, Ga.-based LexisNexis Risk Solutions, concurred. “Patients with serious chronic diseases and rare genetic conditions don’t simply pick up prescriptions with a wave and a nod,” she said. “Their pharmacists provide true personalized care based on patients’ condition and treatment plans, carefully reviewing and explaining proper administration, side effects and the regimen’s other demands and considerations in light of the patient’s overall health status.”
LexisNexis Risk Solutions leverages nonclinical data about patients for insights that help pharmacists better understand a patient’s health risk. Socioeconomic health scores are used to identify individuals who may require attention, helping pharmacy staff better allocate resources and address patient needs holistically. Regan said that pharmacists may inquire about finances, food security or transportation, then connect patients with resources to help solve challenges related to medication nonadherence.
“With predictive analytics as our solutions’ foundation, we’re able to generate insights that put each patient at the center, so pharmacists can make informed decisions for improved outcomes across the counter and all of health care,” Regan said. “As these insights are integrated directly into the workflow, pharmacists are able to seamlessly further value-based care principles amid shifting market trends, making educated decisions about patients in their community with a wellness-focused approach to care,” she said.
Tech companies also are looking to streamline the prescribing process for specialty pharmacies. Among them is Surescripts, whose Specialty Medications Gateway and Electronic Prior Authorization are two new technologies that enable specialty pharmacies to gather clinical information and conduct prior authorizations within their workflow, so that patients can get on therapy faster.
“These tools will help pharmacists spend less time pushing paper, making calls and using faxes, so they get back to what they do best — serving as trusted resources for both their patients and healthcare industry partners,” said Cecelia Byers, Surescripts’ specialty pharmacy clinical product manager.
Besides prior authorization, another challenge that specialty pharmacy operators must contend with is inventory management, particularly important given the higher costs associated with specialty. Kennesaw, Ga.-based KNAPP has a centralized version of its Apostore automatic storage and retrieval system that helps manage medication supplies.
“In the specialty pharmacy space, high-cost medications are automatically inducted and stored in a unique location to assure precise inventory control and First Expired, First Out dispensing of medications,” said Brian Sullivan, KNAPP’s senior systems sales manager of healthcare solutions for the United States and Canada. The KNAPP-Store system can be divided into ambient and refrigerated sections to cover all environmental requirements of the medications.”
KNAPP also offers redPILOT, an automated labor management technology that looks at the output and critical timing goals of a specialty pharmacy and automatically signals labor shifts to meet deliveries and optimize staffing. “When a critical medication has to get out the door, redPILOT uses the pharmacy’s historical data and predictive analytics to assure that the right assets are used to ensure that this happens,” Sullivan said.
Personalizing Patient Care
Aside from using technology, it is critical that retailers are prepared to manage the workload that specialty pharmacy care entails and understand the complexity of specialty medications.
For example, Publix Specialty Pharmacy has five departments. “Publix’s associates are committed to providing the necessary services that will ensure the patient promptly receives their medications with the appropriate support. These services include providing benefits investigation, prior authorization assistance, clinical support with a 24/7 on-call pharmacist, refill reminders, convenient pickup or delivery options, and educational videos,” Do said.
Thrifty White’s Faulks said that a wide range of services is critical. “We want to make sure we treat the whole patient, not half of them. We want to handle any chronic disease they have plus anything else,” he said. “When you talk about all the insurance and financial assistance, clinical counseling and monitoring we have to do with these products, they are a lot more work. Patients who need these medications get much better outcomes from being more actively managed.”
To this end, Thrifty White Specialty Pharmacy’s model leverages its central specialty pharmacy, as well as its local retail locations.
“The model allows us to offer the expertise you need in specialty and allows our local retail pharmacists to maintain that patient relationship,” Faulks said.
Since Thrifty White’s local pharmacists don’t necessarily have the expertise to deal with rare diseases and oncology specialty drugs, the retailer employs multiple certified specialty pharmacists at its central location to counsel patients and to help educate the local pharmacists on how they can support specialty pharmacy patients.
Amber, which is experiencing the largest growth in specialty from new drug launches in rare and orphan diseases, also reflects the expertise that is needed.
“Specialty conditions affect roughly 2% of the population, which means we have the opportunity to develop a relationship with our patients, and it customizes the level of care we are able to offer them,” Wiese said.
As retailers use their expertise to bring new therapies to patients, it also is paramount to help patients with psychosocial issues that can be barriers to adherence.
“Adherence barriers come in many forms, from difficulty accessing transportation to see a physician to assisting a cancer patient with getting a wig because their treatments have caused hair loss,” Wiese said. “We can help our patients rethink the reasons for stopping medication regimens, prioritize the fact that they want to get better, and help meet their needs.”
Amber also employs a certified social worker who connects patients with resources, and a registered dietitian to help patients deal with side effects from medications, such as weight gain and weight loss. “There are specific foods/meals that we can help them prepare by providing recipes,” Wiese said. “A lot of that DNA comes from our grocery background, and understanding how food plays a role in people’s recovery and overall health and well-being.”
Thrifty White also applies strategies to improve patients’ medication adherence, starting with a very in-depth, upfront consultation.
“I am going to talk to you about our programs and what to expect,” Faulks said. “We talk about your disease state and answer questions specific to the drug, and we’ll talk about what side effects to expect, as well as strategies to manage side effects. One of the keys in driving adherence is having those conversations up front.”
Thrifty White has live monthly touchpoints with patients. A technician calls patients seven days before they run out of their medication to see how they are doing, to ask about side effects, and if they have missed any doses — and if any red flags appear, they are referred to a pharmacist for a deeper conversation about adherence, Faulks said
Ensuring Affordability, Safety
Helping patients afford specialty medications, which can carry hefty price tags that range from $1,000 a month to $10,000 a month, is yet another crucial responsibility for retailers in the specialty arena, and it requires a knowledgeable staff.
To help remove financial barriers to adherence, Amber, Thrifty White and Publix are proactive in helping patients reduce their out-of-pocket expenses by connecting them with copay assistance from manufacturers, access to grant and foundation money, and other resources.
“If a patient is diagnosed with cancer, the last thing they should have to worry about is ‘How am I going to pay for this?’ and the journey of working through insurance processes.”
Pharmaceutical firms also are doing their part to make specialty drugs more affordable.
Upsher-Smith’s migraine medications are supported by the Access Pathways Program, a dedicated savings and support team that offers copay assistance and administrative support. Eligible patients pay $0 per prescription for their migraine medication with the Platinum Pass Savings Card.
“The combination of services offered by our Access Pathways Program and our specialty pharmacy partners aligns with our mission to improve the health and lives of patients through an unwavering commitment to high-quality products and sustainable growth,” said Rusty Field, president and CEO of Upsher-Smith.
Retailers also need to be aware that specialty drugs require special handling. Many of the drugs need to be refrigerated, and there are regulations that need to be followed to ensure proper handling and storage of these expensive medications. Additionally, limited-distribution networks for many specialty drugs can be a daunting challenge.
“From a payer landscape side, you see more and more frequent limited networks, where there’s a list of medications that a PBM or health plan will only allow a select group of pharmacies to fill,” Faulks said.
There also is more competition in specialty from health systems and PBMs that have bought specialty mail order pharmacies, so it is imperative that specialty pharmacies continually innovate.
When it comes to innovation, Amber has been using artificial intelligence and machine learning to predict patients’ nonadherence. “We’re able to identify which patients are likely to have more challenges with adherence based on historical patterns, and proactively intervene on their behalf and enroll them in advanced adherence programs,” Wiese said.
Sandra Canally, founder and CEO of The Compliance Team, based in Spring House, Pa., which started accrediting specialty pharmacies in 2006, said that the company’s accreditation model for the specialty sector has changed “to incorporate key principles that guide today’s value-based care era with its emphasis on quality and positive outcomes.”
The company’s Patient-Centered Pharmacy Home accreditation program emphasizes improved patient medication management and care planning through better coordination between pharmacists and prescribers.
“The typical patient with chronic disease is by definition at high risk, and in need of this increased communication as well as better medication management to improve adherence which helps reduce ER visits, hospital readmissions, and lessen prescriber workloads,” Canally said.
As specialty continues to grow, Faulks said he would like all patients to receive the level of care that specialty patients do. “That would be the gold standard for pharmacy,” he said. “Although the economics don’t always allow that, we are making that shift, with better MTM reimbursement and more payer awareness of the services we can provide, we are moving to the ultimate goal.”