Better drug utilization drives specialty pharmacy

Specialty pharmacy is on a roll. A 2011 report by pharmacy benefit manager (PBM) Prime Therapeutics found that specialty products accounted for less than 1% of all prescriptions written in the United States in 2010. But that under-1% accounted for 20% of the total drug spend. Specialty spending could account for nearly 50% of the total drug spend by 2030.

The bulk of the specialty pharmacy spend can be attributed to drugs or biologics used to treat a handful of chronic or low-incidence medical conditions, said Kirby Eng, RPh, director of medical pharmacy management for CVS Caremark. Specialty products are typically biologics or biotech-based formulations that require significantly greater supervision, monitoring, and handling than the typical oral solid or injectable, he said during the American Society of Health-System Pharmacists midyear meeting last year.

Complex dosing schedules and side-effect profiles are the rule, not the exception. And prices can be staggering. Annual therapy costs can hit $250,000 per patient. Costs continue to climb.

New agents enter distribution at the highest price manufacturers judge the market will bear. Competitors are quick to react.

Take fingolimod (Gilenya, Novartis), introduced in September 2010. Multiple sclerosis (MS) was already Prime Therapeutic's second-largest specialty area, accounting for 3.1% of the company's total drug spend. Fingolimod, the first oral disease-modifying agent for MS, commanded a significant premium - and competing manufacturers raised prices accordingly. While utilization increased by 3.4%, the cost per member per month for MS care jumped 15.7%.

"The patient absolutely has to benefit from therapy. Someone has to track compliance to ensure that patients are not underdosing. Someone has to monitor the patient's condition and response to treatment on an ongoing basis. It is the unmanaged patient who is the cost, not the drug. If patients are not being monitored, their condition is not being controlled, and the drug spend is being wasted. That's where specialty pharmacy comes in."