Specialty Pharmacy Feeling the Strain as Financial Needs Increase

August 13, 2018| CATEGORIES: Specialty Pharmacy , Press Mention

Avella EVP of Clinical and Quality Assurance, Eric Sredzinski, was recently quoted in the following Specialty Pharmacy Continuum article.

A perfect storm is brewing as specialty drug prices reach all-time highs, out-of-pocket drug costs increase and financial assistance programs reach capacity.

“While commercial and Medicare Part D patients are seeing rising cost-sharing requirements and greater demand for assistance, the increasing contributions from drug companies over the past five years seem to be plateauing,” Daniel Klein, the president and CEO of the Patient Access Network (PAN) Foundation, said during the Asembia 2018 Specialty Pharmacy Summit.

Specialty drug recipients are being asked to pay for 25% of specialty-tier drugs, which is one reason total out-of-pocket health care costs as a proportion of Social Security income are projected to rise to 50% by 2030, according to a Kaiser Family Foundation report. And this trend shows no sign of slowing, given the steady rise in specialty drug spending.

So far, growing out-of-pocket costs have not dramatically increased the number of Avella Specialty Pharmacy patients who choose not to fill their medications, said Eric Sredzinski, PharmD, the Phoenix-based company’s executive vice president of clinical affairs and quality assurance. “The biggest impact we’ve experienced has been in needing to bolster our organization’s financial assistance component,” he said during an Asembia panel on financial assistance, moderated by Mr. Klein.

Avella has added quality assurance and patient compliance specialists, trained more technicians about financial assistance options and educated patients and clinicians on alternative sources of drugs when there is no financial assistance available. These include patient assistance programs (PAPs) or clinical trials, he said. Staff at Avella also have been spending more time addressing financial assistance needs at the end of the calendar year in anticipation of the first few months of the following year, when patients’ financial needs are greatest, Dr. Sredzinski said. That preparatory work includes assessing plan changes, identifying revised prior authorization criteria and appeals processes and determining whether a PAP is likely to have funds available at the beginning of the year. “It’s become a very complex scenario, and we’re finding ourselves spending more time tracking and trending what’s going on,” he said.

Dr. Sredzinski also noted that because specialty medications sometimes require ongoing laboratory monitoring, his staff looks for PAPs that cover expenses for these tests and travel to the laboratory. “If patients can’t get to where they need to go for testing, access to the drug is sometimes meaningless,” he said.

Carmine DeNardo, RPh, the president and CEO of ReCept Pharmacy, said his company’s employees have had to work harder to match patients with limited sources of funding. “As commercial plan premiums have been rising, we’ve seen more of our patients requiring help finding sources of assistance,” he said during the panel discussion. In addition to educating staff and clinicians, ReCept Pharmacy has developed “very robust patient-by-patient case management programs to map out in detail how the patient can pay for a drug and stay on therapy,” he said.

For cancer patients, out-of-pocket costs are already very high and therefore have not notably increased in recent years, said Paul Jardina, the president and CEO of Onco360 Oncology Pharmacy Solutions, in Louisville, Ky. “Oncology patients typically blow through the coverage gap and fall into catastrophic coverage relatively quickly in the plan year,” said Mr. Jardina, who also took part in the panel discussion. “And we find that patients who don’t get funding tend to fall off therapy sooner, which has an impact on clinical care. Based on our data, patients who receive out-of-pocket funding assistance are on therapy an average of 25% longer than those that did not receive funding.” 

Too Much Gray From White House
Asked whether he was optimistic that the Trump administration’s “American Patients First” plan will reduce patients’ share of drug costs, Mr. Klein said, “I didn’t see anything in the blueprint that directly addressed the high deductibles and high coinsurance that patients are paying today.” But he did note some concern that allowing Medicare Part D plans greater negotiating power in choosing drug substitutions, as the White House plan proposes will happen, may limit access to specialty medications.

“Many of [our] patients use medications that don’t have generic or biosimilar alternatives,” Mr. Klein said. “So we would be nervous if some patients couldn’t access a product, especially one with no alternative, just because the plan has decided not to include it on their formulary.”

The immediate actions noted in the plan that are geared toward reducing out-of-pocket spending—vs. cutting drug prices—“tend to be more educational,” he said. For example, one provision would allow pharmacists to tell patients when they might be able to pay less by not going through their insurer. “That price difference will likely not make a big dent in costs for people with cancer or other serious illnesses, which are the people we work with at the PAN Foundation,” he said. Another provision would introduce measures to inform Medicare Part B and D recipients about lower cost alternatives, which would be “great if there are generic or biosimilar alternatives, but won’t make a difference if there are none.”

Although the government plans to revisit how manufacturer copay cards are regulated, Mr. Klein said the document does not include details on that provision. “There’s also talk of shifting some Part B drugs to Part D, with the hopes that Part D plans can negotiate better prices, but the thing to keep in mind is that under Part B, patients can purchase Medigap [Medicare Supplement Insurance] coverage that covers the 20% coinsurance, while there is no Medigap coverage for Part D,” he noted. “This step could lower the cost of the drug, but the out-of-pocket coverage might actually increase.”

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