New Pharmacy Breed Offers Special Attention, Drawbacks to Patients

Specialty pharmacies have been a health care staple for years. These drug outlets distribute high-cost medications, those requiring special handling, and other drugs whose requirements often fall outside the capability of typical retail pharmacies.

Specialty pharmacies began as private, mainly mail-order companies, and many national drugstore chains now include their own specialty component. But only recently have specialty pharmacies become integrated into cancer care. A recent Drug Trend Report released by Express Scripts, a pharmacy benefits manager, estimated that so-called specialty drugs for illnesses including cancer, multiple sclerosis, and HIV will comprise 26 percent of drug spending by 2010.

The rise of specialty pharmacies in cancer care is directly related to the heightened availability of at-home treatments. The Food and Drug Administration has approved oral cancer drugs for more than 40 indications (includes drugs approved for more than one indication), and many of those approvals occurred in the past decade. Up to 35 percent of cancer drugs in development are for oral formulations, according to experts, while self-injectable medications are also increasingly common.

Insurance providers are attracted to specialty pharmacies because they offer helpful services for patients taking therapies at home, and, because these companies have fewer overhead expenses since most are mail-order, their prescriptions often cost less for the insurer. (Some specialty pharmacies have physical locations in large cities, while others ship medications directly to patients’ homes.)

But like the drugs they sell, specialty pharmacies come with their own profile of benefits and side effects. Awareness of these has become a necessity for patients.

Employing a program called medication therapy management, or MTM, specialty pharmacies act as surrogate health care professionals. “[MTM is] a proactive intervention program with the patient,” explains David Reese, vice president of OncologyRX Care Advantage, a specialty pharmacy launched by US Oncology, a health care services network. “We are trying to mimic what has been occurring in the physician’s office.”

With MTM programs, oncology nurses and pharmacists educate patients about how to take the drug and what side effects to expect, call patients weekly for the first month or two of treatment, and operate a 24-hour telephone hotline. Also, they will alert the doctor at the first sign of a severe toxicity.

Patients also receive phone calls a week before the current bottle of pills is due to finish to ensure timely refills, and the next prescription is delivered to the patient’s doorstep. In addition, specialty pharmacies can often help patients secure co-pay or other financial assistance.

But the use of specialty pharmacies in cancer care can be fraught with problems. Delays at the start of treatment are common because insurers may require patients to fill prescriptions through a specialty pharmacy, eliminating conventional retail outlets from the treatment equation altogether. That requirement is not always clear at the outset of treatment, so patients should ask their insurance provider if using a specialty pharmacy is part of their plan.

Patients and doctors often don’t know if a specialty pharmacy will be required by the patient’s insurance company, says Joseph Muscato, MD, an oncologist with Missouri Cancer Associates who has dealt extensively with specialty pharmacies. But obtaining the necessary prior authorization and then waiting for the medicine to be shipped can delay initial treatments for up to a week, Muscato notes.

Specialty outlets sometimes require patients to receive up to 90 days’ worth of a drug at once. But cancer treatment regimens can undergo frequent changes, possibly resulting in wasted pills, hours on the phone to have alterations approved and processed, and unexpected delays in the next cycle of treatment.

Plus, delivering drugs by mail is risky. Muscato recalls one patient whose kidney cancer started progressing unexpectedly. After some investigation, her medication, which required cool storage, had gone bad in the summer heat, having been left on the porch in her absence.

Reese says OncologyRx Care Advantage requires a signature for all prescription deliveries. As for the delays, many of these are “a factor of the system,” he says, part of the unavoidable health care system red tape. Seeking financial assistance can also delay the process, says Reese.

With oral drugs on the rise, specialty pharmacies are an increasing presence in cancer care. Learning the ups and downs of this change is essential to avoid the pitfalls and find benefit from useful services.