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The Rise of Specialty Pharmacy Costs

Issues for Providers, Payers, and Patients

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Disease Management & Health Outcomes

Abstract

The growth of specialty medication costs is having a visible impact on the market. These drugs — the products of groundbreaking scientific and technological advances in medicine — offer tremendous promise for the treatment of serious debilitating and life-threatening illnesses; however, the average treatment cost per patient for these medicines is about $US18 000 per prescription per year and their use is rapidly growing. This article reviews the unique characteristics of specialty drugs, their profound medical potential, as well as how their cost, complexity, and reimbursement structure are producing unique issues for physicians, plans, and patients. Misaligned interests and incentives are identified as challenges that can affect the dynamic between these constituents whose working relationships are critical to the health system. Resulting mismanagement of specialty drugs could lead to higher costs and reduced outcomes. While society stands to benefit significantly from specialty drugs, investment is needed in programs that align interests and enhance coordination between physicians, payers, and patients. Such programs will drive clinically appropriate, cost-effective use of these medications to ensure the greatest benefit. Among these proposed programs are the development of care guidelines that are customized to patients prescribed specialty medications, the implementation of cost-management programs, timely patient support and education, and the development of effective utilization management programs that clearly define the intent of specialty drug use.

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Notes

  1. LexisNexis is a proprietary US literature database with full text access to >5600 sources.

  2. This study was an internally conducted Express Scripts trial, which has not been published. It was conducted during quarter 1 and quarter 2 of 2006. Unfortunately, additional data such as number of patients and patient demographics are not available.

References

  1. Cohen M, Morrow T, Penna P. Managing the expanded use of biologics across therapeutic areas: an example from b-cell targeted therapies. Am J Manag Care 2006 Mar; 12 (2 Suppl.): S24–37

    PubMed  Google Scholar 

  2. Lotvin A. Specialty pharmacy presents unique set of challenges. Manag Care 2004 Aug; 13(8): 8–9

    PubMed  Google Scholar 

  3. Mullins CD, DeVries AR, Hsu VD, et al. Variability and growth in spending for outpatient specialty pharmaceuticals. Health Aff (Milwood) 2005 Jul–Aug; 24(4): 1117–27

    Article  Google Scholar 

  4. IMS Health. IMS Health reports 5.4 percent dollar growth in 2005 US prescription sales [online]. Available from URL: http://www.imshealth.com/ims/portal/front/articleC/0,2777,6599_3665_77180090,00.html [Accessed 2006 Sep 14]

  5. Miller S, Parker A, Peterson C, et al. Express Scripts 2005 drug trend report [online]. Available from URL: http://www.express-scripts.com/ourcompany/news/industryreports/drugtrendreport/2005/ [Accessed 2006 Aug 31]

  6. Survey shows MCOs are limiting specialty pharmacy services. Specialty Pharmacy News 2006 Jun; 3 (6): 9-10

  7. Express Scripts. Factors predicting patient compliance to specialty drug therapy regimens for multiple sclerosis, inflammatory conditions and hepatitis C [online]. Available from URL: http://www.express-scripts.com/ourcompany/news/outcomesresearch/onlinepublications/study/factorsPredictingPatientCompliance.pdf [Accessed 2007 Mar 15]

  8. Goldman DP, Joyce GF, Lawless G, et al. Benefit design and specialty drug use. Health Aff 2006 Sep–Oct; 25(5): 1319–31

    Article  Google Scholar 

  9. Fried MW. Side effects of therapy of hepatitis C and their management. Hepatology 2002 Nov; 36 (5 Suppl. 1): S237–44

    Article  PubMed  Google Scholar 

  10. Raptopoulou M, Tsantoulas D, Vafiadi I, et al. The effect of adherence to therapy on sustained response in daily or three times a week interferon alpha-2b plus ribavirin treatment of naive and nonresponder chronic hepatitis C patients. J Viral Hepat 2005 Jan; 12(1): 91–5

    Article  PubMed  CAS  Google Scholar 

  11. Data on file, 2006 Express Scripts study: analysis of prescribers of specialty medications during Q1–Q2, 2006

  12. Sullivan SD. Consensus guidelines for specialty pharmaceuticals: a best-practice approach for cost-effective management. Am J Manag Care 2004 Aug; 10 (8 Suppl.): S242–4

    PubMed  Google Scholar 

  13. Adams CT. The off-label conundrum. Biotechnol Healthcare 2006 Apr: 27

  14. Kocs D, Fendrick AM. Effect of off-label use of oncology drugs on pharmaceutical costs: the rituximab experience. Am J Manag Care 2003 May; 9(5): 393–400

    PubMed  Google Scholar 

  15. Golenski JD. Specialist discretion for managing specialty pharmaceuticals: the ethics argument for discretion. Am J Manag Care 2004 Aug; 10 (8 Suppl.): S240–1

    PubMed  Google Scholar 

  16. Specialty pharmacy experts share insights on member cost-sharing. Specialty Pharmacy News 2005 Feb; 2 (2): 9

  17. Centers for Medicaid and Medicare Services. CAP for Part B drugs and biologicals [online]. Available from URL: http://www.cms.hhs.gov [Accessed 2007 Apr 13]

  18. MCOs’ oncology strategies focus on provider issues for 2005. Specialty Pharmacy News 2005 Apr; 2 (4): 6

  19. Shifting physicians from buy & bill. Specialty Pharmacy News 2005 May; 2 (5): 7

  20. Mullins CD, Lavalle DC, Pradel FG, et al. Health plans’ strategies for managing outpatient specialty pharmaceuticals. Health Aff (Milwood) 2006 Sep–Oct; 25(5): 1332–9

    Article  Google Scholar 

  21. Mullins CD, DeVries AR, Hsu VD, et al. Variability and growth in spending for outpatient specialty pharmaceuticals. Health Aff (Milwood) 2005 Jul–Aug; 24(4): 1117–27

    Article  Google Scholar 

  22. Goldman DP, Joyce GF, Lawless G, et al. Benefit design and specialty drug use. Health Aff (Milwood) 2006 Sep–Oct; 25(5): 1319–31

    Article  Google Scholar 

  23. Consultant: many employees are still in learning stage of specialty pharmacy. Specialty Pharmacy News 2005 Oct; 2 (10): 11

  24. Specialty pharmacy experts share insights on member cost sharing. Specialty Pharmacy News 2005 Feb; 2 (2): 9

  25. Goldman DP, Joyce GF, Lawless G, et al. Benefit design and specialty drug use. Health Aff (Milwood) 2006 Sep–Oct; 25(5): 1319–31

    Article  Google Scholar 

  26. Enbrel® [package insert]. Seattle (WA): Immunex Corporation, 2005 Jul 25

Download references

Acknowledgments

No funding was provided for the research or preparation of this article. All authors and contributing authors are employees of CuraScript, Inc. or Express Scripts, Inc. CuraScript is wholly owned by Express Scripts, which is a publicly traded diversified healthcare company principally focused on specialty pharmacy, biotech distribution, and related services that owns or operates several other businesses, including (but not limited to) pharmacy benefit managers and several mail service pharmacies. Each of the authors and contributing authors may own stock, or have other financial interest(s), in Express Scripts. More information on Express Scripts can be found in its public filings with the Securities and Exchange Commission. Additional individuals who have contributed to the development of this material are Emily R. Cox, R.Ph, Ph.D; Raulo S. Frear, Pharm.D; and Brian Seiz, Pharm.D, all of whom were employees of Express Scripts at the time of preparation of this article.

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Correspondence to Tracy A. Hoffman.

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Miller, S.B., Hoffman, T.A., Houts, J.C. et al. The Rise of Specialty Pharmacy Costs. Dis-Manage-Health-Outcomes 15, 83–89 (2007). https://doi.org/10.2165/00115677-200715020-00003

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