In a 2-part Q&A with Specialty Pharmacy Times, NASP President Rebecca Shanahan discussed how direct and indirect remuneration (DIR) fees affect specialty pharmacy, how to improve patient outcomes, the impact of Any Willing Provider legislation on payer access and patient services, and many other hot topics in the specialty landscape.
SPT: Compare the impact of DIR fees on specialty pharmacy and the differences in the specialty pharmacy model compared with traditional retail?
Shanahan: It’s no surprise that specialty and retail are really challenged by these fees. I think for retail the challenge is that 1, it’s a significant fee, but 2, it’s probably pretty difficult to track and forecast because of the way that the (pharmacy benefit managers) PBMs have set up the operation and implementation of the algorithms around the fees. So they end up being applied, not at the point of sale, but sometime thereafter, retrospectively. For a retail pharmacy, that becomes pretty challenging, particularly through an independent retail pharmacy, and your ability to have lots of analytics and forecasting coming out of your pharmacy system is limited. I think it’s been a real challenge for everybody, but particularly for the retail pharmacies.
The National Community Pharmacist Association (NCPA) just came out as identifying DIR fees as their number 1 issue, and seeking a sort of a policy goal for them and the retroactive nature of the direct and indirect remuneration fees. We at NASP also believe this is a critical issue for us. It’s an issue, in part, because of how dramatically it’s grown in such a short period of time. I think that the CMS report that just came out said that DIR revenues grew approximately 22% a year, and about 14% per year, per-member per-month. That’s a dramatic increase in revenue for the PBMs, but also a dramatic increase in the charges for us.
For specialty pharmacy––particularly in a differentiated manner––the way that these programs are being applied is they are measuring performance of specialty pharmacy against what we would consider to be traditionally retail oriented metrics of performance. Metrics related to the adherence and persistence on diabetic therapies and/or on statins are not things that are high incidence in specialty pharmacy populations. We predominately treat patients with life-threatening and/or unique chronic diseases that are usually of a smaller population with a higher cost. So for us to be measured in a way that applies not to the patients that we are serving, or that really does not allow us as specialty pharmacies to influence performance, you can’t really say that as these metrics are applied to specialty pharmacies, they are applied to drive performance of clinical outcomes because we are not in a position to influence those clinical outcomes with respect to those kinds and categories of patients.