There is a lively (to be diplomatic) debate going on among manufacturers, specialty pharmacies (SPs) and outsourced hub providers over how best to serve patients that need specialty pharma therapies. Most of the time, these drugs are distinguished from conventional pharmaceuticals by having complex administration requirements (infusion, injection), close monitoring of effects and adverse events, and high cost. The cost, in turn, generates another requirement: prior authorizations from payers and/or step edits to control which therapy is tried first.
The complexity of specialty pharma dispensing is what led to the rise of hub services in the first place. Now, however, there is a degree of friction between hub providers (some of which are run by pharma companies themselves) and SPs over who is in the best position to assist patients. One of the main areas of contention is how can patients get “on therapy” quickest—directly from the SP, or with the intervention of the hub provider? Prometrics, a King of Prussia, PA data aggregator of pharmacy data, finds multiple difficulties in resolving this question: for one thing, different therapies have different dispensing steps; for another, the various parties have different perspectives on when the therapy started and when the prescription was filled. The prescribing doctor would like the prescription to be filled as soon as the scrip is written; but the hub starts the process when the request for patient support is made; and the SP when a scrip is delivered to it. A key step is prior authorization; papers need to be obtained and then filed, awaiting a payer decision. Electronic prior auth (ePA) can speed up some of this process, but the ePA system needs to be in place for that to occur.
In its latest survey,* conducted over the summer, Prometrics found that speed-to-therapy is usually determined by the manufacturer (Fig. 1)—but the manufacturer is seldom in the best position to make that determination. Reasons for delays in speed-to-therapy also have perceptual differences (Fig. 2); manufacturers and SPs cite the same factors, while hubs have a different ranking of those factors.
The Prometrics survey asked manufacturers point-blank whether hubs delay speed-to-therapy; 45% of respondents believed that they do—but that in many cases, this is justified by the patient support services offered. SPs were asked the same question, and responded by a 64% margin that hubs were a cause of delay—and an unnecessary one because the SPs themselves can handle prior authorization and getting patients on therapy.
From a manufacturer’s perspective, speed-to-therapy is important because the quicker the patient can begin treatment, the more durable the relationship is between that patient and that therapy (especially for chronic conditions). This is doubly true during the product launch phase; over-long delays can cause physicians to look to other therapies or not to start the newly launched drug at all. And while the SP-hub conflict is likely to continue, hubs are often in a position to best handle the scrip handoff, including arranging for “fast fill” programs where a drug is dispensed on the expectation that prior auth will be addressed satisfactorily (which is a risk that some manufacturers are willing to take).
“Manufacturers need to be aware of this conflict while setting up their distribution and patient services strategy. Aligning specialty pharmacy network and Hub will result in better outcomes for patients and better coordination with HCPs,” is one of the recommendations Prometrics makes based on the survey.