Industry Voices—Integrating pharmacy into specialty practices improves access, care

Getting diagnosed with cancer or another life-altering illness can overwhelm patients, who suddenly face a complex condition while worrying about their future, family and finances. The ability to quickly access prescribed specialty medicines shouldn’t add to those worries, but in today’s complicated health system it often does — and not just because of high out-of-pocket costs.

Increasingly, health insurance middlemen called pharmacy benefit managers, or PBMs, are forcing patients to use the PBM’s own mail-order pharmacy to obtain their prescriptions. These drugs treat complex, often chronic conditions from cancer to autoimmune disorders such as rheumatoid arthritis, multiple sclerosis, and inflammatory bowel disorders. 

For anxious patients, dealing with a PBM’s mail-order pharmacy often is inconvenient, frustrating, and impersonal. Worse yet, the red tape and slow response from PBMs —which face limited competition—can delay therapies patients urgently need or leave patients pleading for prescription refills shipped before they run out of medicine. Both problems can worsen patient outcomes and cause undue stress.

There’s a far more efficient way to handle this, both for patients and doctors: provide the prescribed medications at the cancer clinic or academic medical center where the patient regularly goes for testing and medical appointments. Embedding a specialty pharmacy within the practice—called medically integrated dispensing (MID)—dramatically improves the healthcare experience by removing the PBM-controlled specialty pharmacy from the “triangle of care”—the doctor, the patient, and the pharmacist.

Research has demonstrated the benefits of MID. One 2020 study showed oncology patients who obtained cancer medicines at their hospital or clinic started on their medication sooner and complied with the dosing schedule much better than patients getting medications from an external specialty pharmacy, with 95% adherence versus 70%. Another study found dispensing medications to patients at pharmacies inside several Idaho cancer centers reduced medication waste and other costs, saving insurers considerable money compared to patients whose prescriptions were filled by PBMs.

While integrated specialty pharmacy services are not new, they are becoming a more popular model of care as doctors push for more control over the medications they prescribe. Maryland Oncology Hematology (MOH), the largest cancer clinic in the state of Maryland, launched its MID program about five years ago, during which time the improved healthcare experience has been dramatic; communications between patients and their care team improved which led to fewer delays in obtaining treatment and higher rates of medication adherence. When problems arise, such as the need to make time-sensitive dose adjustments, doctors are able to communicate in a more timely and efficient manner with the in-house pharmacy.

Further, a recent abstract in the Journal of Clinical Oncology concluded that “medically integrated dispensing of oral oncolytic therapies allows for increased pharmacy oversight, leading to increased cost avoidance and reduced waste for patients and third-party payers.”

However, creating in-house pharmacies can be costly and requires specific expertise and technology. For some smaller oncology and specialty medicine practices, such an investment could be a hurdle. But recently those obstacles have been addressed by contracting with companies that have the software, technology, and experience to set it up and help them manage it.

One example is specialty-pharmacy startup House Rx, which provides technology platforms and infrastructure resources focusing on patient needs. Its own research shows House Rx sends insurers required prior authorization paperwork within a day of medicine being prescribed, patients get their drugs at least 10 days faster than when dealing with external specialty pharmacies, thus saving clinic office staff dozens of hours a week in time spent dealing with forms and waiting on hold with insurance companies. House Rx also proactively assists patients with seeking foundation grants or low-income subsidies to help cover copays.

Over the last few decades, PBMs have instituted procedures that can limit or delay patient access to medication, with the aim of lowering insurers’ costs and maximizing PBM profits from processing claims for mass-market drugs like cholesterol and blood pressure medications. Now PBMs are adapting those tactics for specialty drugs, whose use and list prices have increased so much that spending now totals over half of all U.S. prescription drug costs.

Three major PBMs—CVS Caremark, Express Scripts and OptumRx—dominate the specialty drug market, controlling 80% of all prescriptions while also making millions from fees they charge drugmakers for preferable coverage of their medicines. PBMs are less regulated and transparent than health insurers, hospitals, and even drugmakers, yet they are able to dictate which drugs insured patients can receive and how much they cost. They do this by requiring the insurers they’re affiliated with to use only those specialty pharmacies owned or controlled by the PBM.

No third party should have control over how, when and where patients get their medicines. Patients and their providers should be making these decisions. Allowing monopolies like PBMs to dictate which medicines are dispensed and when they are delivered puts control in the wrong hands. In-house pharmacies offer an alternative and favorable approach, which can dispensaries empower doctors and patients while facilitating better compliance, access, and outcomes.

Terry Wilcox is the executive director of Patients Rising, a non-profit patient education and advocacy organization that helps patients get access to essential diagnostics and the treatments they need.