Plan Sponsors Prefer Specialty Pharmacies Over Retail Drugstores

Top 'o the morning to you! Let’s take a wee look at the Pharmacy Benefit Management Institute’s (PBMI) new 2018 Trends in Specialty Drug Benefits. (Free download with registration.) It’s a great resource for understanding how plan sponsors manage specialty drugs.

The new report contains fascinating data showing how sponsors of employer-based health plans view dispensing channels for specialty drugs. As you will see below, employers believe that the capabilities of specialty pharmacies are superior to those of retail pharmacies. They also think that over the past few years, specialty pharmacies’ performance gap has widened for crucial clinical and patient services.

Being a specialty pharmacy has become as fashionable as a #unicornmarshmallow. The PBMI’s data partly explain specialty pharmacies’ market position is more than just the luck of the Irish.

THE MOST MAGICAL PART OF THE DATA

The PBMI survey collects data from employers, not PBMs. The 2018 edition of its specialty report includes responses from 299 employer-sponsored plans that offer prescription drug benefits, accounting for an estimated 15.9 million covered lives. Drug Channels tips its cap to Walgreens and AllianceRx Walgreens Prime for having sponsored this valuable research.

The specialty report complements PBMI’s 2017 Trends in Drug Benefit Design, which I discussed in Employers Are Extracting More of Their Rebate Dollars from PBMs.

Both reports include some of the same questions, so you can compare benefit designs of traditional vs. specialty drugs. For some examples, see our comparative analysis of rebates in Section 5.3.2. of our new 2018 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers

GOING AFTER ME LUCKY CHARMS

In addition to basic product dispensing, specialty pharmacies provide various services beyond those typically needed for a traditional drug dispensed at a retail drugstore. These services typically include:

• Providing disease-specific patient education
• Performing patient therapy management, including supporting adherence and providing side effect counseling
• Providing ready telephone access to a nurse or pharmacist
• Managing patients’ prior authorization and other health insurance eligibility coordination for specialty medications
• Helping financially needy patients apply to manufacturers’ patient assistance programs
• Meeting special product handling, storage, and distribution requirements
• Providing information about patients to healthcare providers
• Assisting with clinical information flow among clinicians treating patients
• Providing hearts, stars, horseshoes, clovers, blue moons, pots of gold, rainbows, and tasty red balloons. (Note: I’m not sure about this one.)

Unlike a retail pharmacy, a specialty pharmacy will often submit to the manufacturer detailed, patient-specific data for each prescription dispensed. All patient data must be de-identified to protect patient privacy, per the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

A pharmaceutical manufacturer may directly compensate specialty pharmacies for clinical and patient services that are linked to meeting defined performance criteria.

SHAMROCK SHAKES

The PBMI survey data quantify payers’ beliefs that specialty pharmacies’ capabilities are magically delicious compared to those of retail pharmacies.

The survey asked employers whether specialty pharmacies are “better,” “worse,” or “equal” to retail pharmacies on four metrics:

• Unit price

• Clinical programs

• Access to copayment assistance programs

• Ability to interact with a pharmacist

The chart below summarizes our analysis of the results. For comparison, we include the figures from 2014.

[Click to Enlarge]

As you can see, employers perceive that compared with retail pharmacies, specialty pharmacies have lower prices, better clinical programs, and more access to copayment programs. Employers also perceive that specialty pharmacies’ performance relative to retail pharmacies has improved from 2014 to 2017. Note the increase in the “specialty pharmacies are better” (blue bars) component.

An exception to payers’ preference for specialty pharmacies is their belief that retail pharmacies offer patients a greater ability to interact with a pharmacist. Retail pharmacies’ perceived performance on this metric has improved over the past few years. This is not surprising given that specialty pharmacies typically dispense via the mail rather than relying on the patient’s picking up a prescription in person at a pharmacy location.

As a result of specialty pharmacies’ perceived performance, both manufacturers and payers can and do limit the dispensing of specialty drugs to a defined set of designated pharmacies. That’s a key reason why a handful of pharmacies collect the pot of gold at the end of the specialty rainbow, per the market share data in The Top 15 Specialty Pharmacies of 2017: PBMs and Payers Still Dominate.

P.S. Celebrate St. Patrick’s Day with this hilariously serious history of the marshmallows in Lucky Charms cereal. Sláinte!