Healthcare Technology Featured Article

July 12, 2013

Leveraging HIT to Improve Specialty Medication Processes

Specialty medications help extend the life expectancy of millions of patients and improve the quality of life for millions more. Despite their value and growing use, they are expensive for payers, patients and society alike. As a result, stakeholders are looking for ways to make specialty medications more affordable and accessible to those patients who need them. One possibility is to leverage health information technology (health IT) to reduce the costly administrative overhead associated with the antiquated phone, paper and fax-based processes still dominating specialty medication prescribing. The time is right to plan for the future and get the ball rolling.

Arguably, the aspect of specialty drugs that garners the most attention is their cost. While the sticker price varies, specialty medications are often priced at more than $2,000 per month per patient. Many cost much more, and the most expensive specialty drugs run between $100,000 and $750,000 annually. 

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Specialty medications represent the fastest growing segment among healthcare expenditures. According to Express Scripts, outlays are expected to jump nearly 70 percent by 2015 due to numerous factors, including the rising number of patients taking these drugs for chronic illness and our aging population. In addition, many new specialty drugs are expected to be approved for such conditions as cancer, multiple sclerosis, hepatitis C and rheumatoid arthritis, which also will contribute to the expected rise in expenditures for specialty medications and their utilization.

The environment surrounding specialty medications is complex and overhead is high. While an increasing number of high-volume specialty medications – such as insulin and rheumatoid arthritis medications – are being dispensed in retail pharmacies, specialty medications are generally dispensed by specialty pharmacies. This is due in large part to the need for specially trained, dedicated clinicians to help manage therapy in addition to ingredient shelf lives and inventory cost, among others. The ordering process is multifaceted and depends on a variety of information that is not standardized or required in today’s paper world, such as prior therapy regimens.

While the overhead is both extensive and expensive, much is due to the fact that nearly all specialty medications require prior authorization (PA). Today, PA consists of antiquated paper-fax-phone methods that are major productivity drags for payers, pharmacies and providers. This negative productivity impact carries major financial implications. For example, it is estimated to cost physicians between $21 billion and $32 billion annually to process paper-based PA requests.

In addition, the hassles and time lags inherent in PA’s lengthy and burdensome administrative processes prevent many patients from getting the medications they need. 

Furthermore, in the ordering process, it’s critical that the appropriate pharmacy options are identified, yet this is hit-or-miss because most ePrescribing functionality is not designed to identify a preferred pharmacy – just the previous or, in some cases, mail service pharmacy. It’s also critical that, if PA is required, the drug includes a PA flag. However, the PBMs that provide the PA flag are few and far between. The process is so cumbersome that the chief medical officer of an ePrescribing company tells us that he – a technology evangelist who makes designing and using technology a priority – has his staff spend time on the burdensome task of ordering specialty medications instead of bothering to doing so himself.

Then, once the dispensing pharmacy gets the order/prescription, a phone call is made to the ordering provider to confirm that he or she wrote the order and filled in the information. The patient and his or her insurance company are often contacted as well, in a less-than-optimal workflow that is reminiscent of the 1990s.

Health IT solutions can help reduce overhead costs associated with specialty medications and get the proper medications to the appropriate patient in a timely manner. And it’s time for stakeholders to plan for implementation, for the following reasons:

  • There is a robust core infrastructure, especially with regard to orders. According to the latest data from Surescripts, 69 percent of office-based prescribers are ePrescribing. Most prescriptions (87 percent) are created and sent to the pharmacy electronically from electronic health records (EHRs). The technology and infrastructure already exist, so it isn’t a stretch to include all specialty medications in the ePrescribing workflow, as some are still being written on paper, even when the prescriber can write prescriptions electronically.
  • ePA is possible. Prior authorization is a key strategy to help curb inappropriate use of specialty medications and hold down costs. Simple modifications to the electronic prescription process could eliminate the need for PA. In the meantime, a newly standardized transaction framework for electronic prior authorization (ePA) will be available this summer. ePA allows the provider to electronically request a PA question set from the payer, electronically return the answers and receive a nearly real-time response. This sets the stage for expanded use of ePrescribing of specialty medications and the electronic handling of PA requests. All of this should significantly cut administrative overhead.
  • There has been an evolution of electronic care management tools and processes that help patients and clinicians manage therapy more efficiently and, with tweaks, potentially at a lower cost.  

While progress has been made, there are opportunities to leverage health IT to streamline administrative processes for prescribing specialty medications and to reduce overhead costs. Examples include:

  • Add the diagnosis to the prescription order. Diagnosis is a key piece of information that could reduce the need for some PAs or help speed processing of others. Diagnosis is increasingly available upfront because EHRs capture it for billing and quality reporting, and EHRs are used to create the vast majority of ePrescriptions. The move toward ICD-10 also will provide the additional granularity that many payers require to process PA requests, and ePrescribing vendors have already built systems to accommodate these new codes. As a result, diagnosis could easily be incorporated into an ePrescription. Diagnosis is not mandated for ePrescribing today because it is not required on paper prescriptions.
  • Add other useful information. In addition to diagnosis, other useful information is missing that could help speed the processing of ePrescribing for specialty medications. For example, laboratory values, patient information (such as weight, which is a critical element in dosing) and other indicators need to be passed to the pharmacy. Payers often request these kinds of information as well. While medication history is available for many patients, it is provided only about half the time in ePrescriptions. Adding such valuable pieces of data could help speed processing for specialty medications.
  • Sort out dosing issues. Clarifying how specialty drugs are to be administered and in what quantities are major sources of “to-ing and fro-ing” between pharmacies and prescribers, the time and workflow costs of which drive up administrative overhead. Dosing specificity issues also have major patient safety implications. As mentioned, dosing for specialty medications depends on a variety of factors, including a patient’s weight and laboratory values. This information generally is not provided on paper prescriptions and is unavailable on ePrescriptions, unless it is provided in the text field. In addition, specific dosing instructions can be complex, again depending on a range of patient information, method of administration (such as infusion or injection), and quantities and strength (such as micrograms per milliliter).

The relationship between quantities, strength and method of administration, in particular, may require conversions that are not handled in today’s ePrescribing systems. The codified SIG (patient instructions) standard is on the horizon and will help to resolve some, but not all, of these issues.

Payers, plans and pharmaceutical manufacturers must make prescribing for all medications safer, faster and more cost effective. In turn, the pharmacy industry and vendors will have more work in store when it comes to building in the additional information needed — beyond today’s core data — to safely ePrescribe specialty medications. And payers will need to make changes in what they require in terms of ePA for specialty drugs and indicate which pharmacies can be used to dispense specific specialty medications.

Edited by Alisen Downey
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