Bringing Prescribing and Fulfillment of Specialty Medications Into the 21st Century
By Lathe Bigler
Although electronic prescribing (ePrescribing) is now commonplace at health systems across the country, one major exception is for specialty drugs. To this day, patients sometimes wait upwards of a month to receive specialty prescription medications while standard drugs can be picked up at a local pharmacy in less than an hour.
That is because specialty drugs—typically due to their higher cost and lower inventories—still face an archaic, manual, and largely paper-based prescribing and fulfillment process. Enrollment for a specialty drug prescription, for example, involves faxing and/or scanning and emailing paper forms. Often, to prescribe the specialty drug, the physician must write a letter requesting the health plan to cover it and provide lab and/or test results to verify medical necessity. Meanwhile, the patient, who typically has a complex, difficult-to-manage health condition, waits needlessly for a drug that they hope will improve their health and quality of life.
Prescribers, pharmacies, pharmacy benefit managers, and other stakeholders, however, are finally realizing that things do not have to be this way. By modernizing the process and applying automation where it is currently lacking, everyone—most importantly, patients—will benefit.
A growing problem
Long waits for fulfillment are an especially pressing problem because specialty drug utilization is growing. In a six-year period, specialty pharmacies grew by 315%—from 378 in 2015 to 1,570 in 2021. Specialty drugs now account for 40% of drug spending. The aging population, increased patient complexity, and continued growth of chronic conditions are only going to drive further demand for these drugs.
Although adherence to specialty drug therapies tends to fare slightly better than adherence to standard medications, significant waits between prescribing and fulfillment increase the risk that a patient will not take a specialty drug as prescribed. Cost can be another nonadherence factor; some specialty medications reach $130,000 a year per patient or more, which can result in patients abandoning their treatments altogether.
Non-optimized medication therapy—including nonadherence—costs $528.4 billion, equivalent to 16% of total U.S. healthcare expenditures. A study specifically on nonadherence, conducted in 2017, estimated that the disease-specific economic cost of nonadherence ranged from $949 to $44,190 per patient. In addition, overall costs attributed to nonadherence ranged from $5,271 to $52,341 per patient.
These costs are due to avoidable emergency room visits, hospitalizations, and readmissions as well as missed workdays, lack of productivity, disruption to family member schedules, and other consequences of poorly managed conditions. If a patient could receive their specialty medication more quickly after it is prescribed, they could begin the therapy while their consultation with their provider is still fresh in their mind and their motivation for behavior change is strong.
Modernizing the process
The specialty drug prescribing process is long overdue for an update. By modernizing systems, such as through auto-generating enrollment forms for specialty medications within prescribers’ electronic health record (EHR) systems and electronically delivering them to specialty pharmacies, we could significantly accelerate prescribing and fulfillment. As a result, patients could start their therapy in just a couple of days instead of several weeks and avoid worse outcomes, given that as many as 11% of hospital admissions are due to medication nonadherence.
Prescribers, pharmacies, and payers would also benefit by reducing the costly waste and overhead associated with faxing documentation and fielding phone calls. For example, 74% of pharmacy communications to a physician’s office involved new prescriptions, with the main reason being prior authorization. In some cases, prior authorizations took more than 14 days to resolve. Automating the communication and documentation and eliminating the paper-based steps would go a long way to improving the experience for everyone involved.
Simplifying and standardizing this process for clinicians is especially important given the healthcare industry’s historic staffing crisis. The stress and burnout among physicians and nurses are covered in the news, and pharmacists are struggling with the same work environment and mental health challenges. Burnout poses significant patient safety issues with delayed prescription fulfillment, potential errors due to high volume, long hours, and pressure to meet performance metrics. The growth of specialty drugs and pharmacies and the highly manual, time-consuming process pharmacists must endure will only add to these challenges.
Driving needed change
To date, specialty pharmacies have been unable to participate in ePrescribing due to the lack of documentation standardization across the associated drugs, diagnoses, payers, and prescribers. The lack of standards and outdated administrative steps make it challenging for EHR and pharmacy management system technology developers to improve their solutions in ways that can simplify the prescriber and pharmacist experience and get patients their medications sooner.
In 2022, when so much of business is automated, mobile, and on-demand, it is frustrating that important medications for complex health conditions are so difficult to access and require patients to fill out paper forms and make monthly calls to request refills.
The tools to streamline and modernize the process of specialty drug prescribing are within our grasp today. Healthcare stakeholders just need the collective determination to demand and implement these systems and workflows to eliminate the archaic documentation processes, faxes, and phone calls that increase costs and contribute to fulfillment delays.
Most importantly, modernizing the process across all stakeholders will mean patients can promptly access the therapies that will help them achieve better outcomes, improve their care experience, and use fewer healthcare services.
Lathe Bigler is vice president of clinical network services at FDB (First Databank) and general manager of FDB Vela™, the nation’s second ePrescribing network, which launched in 2022.