RSN: Enabling specialty at retail
The urgency behind Diplomat’s launch of its Retail Specialty Network isn’t hard to fathom. As the growth momentum in pharmaceuticals shifts from traditionally developed drugs to more complex and expensive specialty and biotech products, traditional pharmacies without access to these specialized medicines — and the patients who depend on them — find themselves stranded in a receding market like boats at low tide. And the loss of patent protection and market exclusivity for many of the biggest-selling blockbuster drugs that used to drive top-line sales has accelerated the trend.
"The chains have seen a tremendous fattening of traditional growth," said Diplomat CEO Phil Hagerman. "The generic wave … helps support margins, but doesn’t drive top-line growth. And the industry has come to realize that if you don’t put a stake in the ground around specialty, you’re going to lose that business. Specialty is growing at 20% to 24% a year, where traditional pharmaceuticals now is growing at 2% to 4%."
What’s more, said Atheer Kaddis, SVP sales and business development, a pharmaceutical maker can use direct or indirect means to limit distribution of high-touch drugs and freeze traditional community pharmacies out of the picture. "You don’t necessarily have to create a limited-distribution panel," he said. "You can create barriers to reporting that are so high that indirectly you lock out the retail pharmacies."
"It’s not just the performance measures they’re looking at," he added. "It’s the actual volume and type of data that has to be reported: turnaround times, prior-authorization success, side-effect management and success, compliance and persistence programs that require you to exceed 90% medication possession ratios. So now you have managed care and PBMs locking out retail pharmacies, and pharmaceutical companies, saying, ‘Are you contracted with these PBMs and payers?’ And the retail pharmacy has to say, ‘No, we’re not anymore. We’re locked out.’ So it’s a Catch-22."
All these challenges point to one essential factor that keeps most retail pharmacy operators — excluding the few big chains with their own specialty pharmacy divisions — from competing on their own in the rapidly expanding specialty pharmacy arena: the prohibitive cost of entry.
Enter Diplomat. In 2009, the company launched its Retail Specialty Network to allow retail pharmacy chains and independents to gain entry to the specialty arena. How? By partnering with an experienced specialty pharmacy that can provide the back-end resources, the patient support and the close collaboration with pharmaceutical suppliers and managed care plans that retailers need to compete in specialty pharmacy.
"The most important challenge a retailer has here is not that they lose a high-cost biologic drug," Hagerman added. "The most important thing we do for them is protect their market basket."
"A mass merchandiser with a pharmacy department may have a patient on six or seven drugs plus one complex biological. But the market basket is over $200 every time the patient walks through the door. And if that merchandiser doesn’t have that complex medication, that patient can walk out and go to a competitor," Hagerman said.
Drawing on Diplomat’s expertise and back-end resources also allows a retailer to connect its pharmacy customers with a team of funding and insurance specialists whose job it is to link patients with sources of financing, charitable grants and co-pay assistance to help them shoulder the high out-of-pocket costs of specialty drug therapy.
As the behind-the-scenes specialty resource provider for retail pharmacies that participate in its programs, Diplomat also provides additional services that allow front-line retail pharmacists to offload other time-consuming duties that come with the specialty pharmacy turf. For instance, said VP operations Robert Fleckenstein, if a patient comes into the store with a new prescription that requires prior authorization, "we can help the patient through whatever insurance hurdles there may be."
Added Kaddis, "We’re trying to send the message that you can have specialty at retail." Managed health plans, payers and pharmaceutical companies, he said, should be aware that including retail pharmacies in a specialty network means offering patients "the benefits of convenience, and the ability of patients to interact with their pharmacists face-to-face, and yet still get the value of specialty intervention. We have made a commitment as a company to support various models of distribution of specialty pharmaceuticals. When specialty at retail is embraced by retailers, payers and manufacturers, we want to be there to provide support.
"And that can be a huge win-win for everyone involved," Kaddis noted. "It’s definitely a win for the patient, who can continue to get his or her traditional and also specialty medications at retail. It’s a win for the retailers because they keep that patient and that relationship. And it’s a win for managed care, because…they can still offer specialty drugs at retail and get that benefit for their patients."
For managed care, Diplomat offers broader focus
Any specialty pharmacy provider that wants to succeed in today’s healthcare arena has to align its capabilities with patients, prescribing physicians, hospitals and pharmaceutical manufacturers. But success also depends on delivering cost savings and high-touch patient care services to managed care and health plan payers that depend on it.
Diplomat does so holistically. The company now provides specialty medications as an exclusive or preferred provider for some 12 million members of health plans, and it does present itself to insurers and managed care operators as a source of competitive pricing and data-driven, highly efficient delivery on high-ticket specialty drugs. But Diplomat also works to engage payers and plans at a higher level, with a focus on bigger-picture cost savings that accrue to patients and their health plans over the long term.
The managed care industry’s obsession with the costs involved with covering patients who require specialty drug therapy is easy to understand. Said Atheer Kaddis, Diplomat’s SVP sales and business development, "their main focus right now is controlled utilization of product, and ensuring they’re getting competitive pricing from specialty pharmacies."
"It’s becoming the norm to see drugs that are $100,000 or $150,000 per patient per year in the specialty arena," Kaddis added. "So it’s a big area of focus for payers and managed care."
Nevertheless, managed care organizations should look at costs in a larger context to generate real long-term patient care savings, said VP clinical services Gary Rice. "Even though managed care may initially focus only on [dollar savings], when we start talking about the high-touch programs we offer and the way we can assist patients in their therapy so the investment in those products is optimized, a lot of managed care payers start to see the value equation," Rice said.
For instance, he noted, "in the worst-case scenario, you spend $8,000 a month on an oncolytic, and the patient takes it only half the time. So the disease progresses, and now the patient has to go on a different therapy. That’s more of a cost impact for that managed care organization than getting a 10% discount. So we’re trying to demonstrate responsible fiscal management through our high-touch programs."
Among those high-touch offerings: "We call every patient every month, not only to see how they’re doing, but to see how much product they have left," Rice explained. "And if they have more product than what they should, … we move that delivery to when they really need the product. Those are all cost savings for managed care."
In addition, Rice said, Diplomat’s technology and clinical support teams have been working over the past year "to create more clinical decision trees in our eNAV information technology platform that will allow us not only to manage the patient more efficiently, but also be better able to report those activities to managed care and pharmaceutical companies."
For example, he added, "every time we adjust an inventory for a patient we’re saving managed care costs. Today, I have to figure that out manually. Our goal in the future is to be able to run a report."
For one very small health plan, Rice added, "we were able to save that company more than $300,000 in costs in one year, just by adjusting [dispensing practices] to reduce excess inventory. And they were amazed."
A major focus for Rice’s clinical care team is improving quality and educating both its own clinical support team and those of its provider partners, including retail pharmacists that use Diplomat as their back-end specialty service provider. To that end, Diplomat’s senior director of education and quality, Jennifer Hagerman, drew on her experience as an educator and pharmacy school professor to launch Diplomat University as a fully staffed training tool and educational resource for employees.
"The goal was to implement a comprehensive, robust new-employee orientation program. And once we did that, we evolved into clinical, operational, systems and leadership training," Hagerman explained. "Our next initiative was taking it to our external partners."
Under her leadership, Diplomat also supports a full-year post-graduate pharmacy residency program, which is currently undergoing accreditation from the American Society of Health-System Pharmacists.
"We’ve been very successful … keeping them with our organization after completion of the program," she said.
CEO Phil Hagerman summed it up, saying, "Diplomat will continue to grow dramatically, both in terms of high dollar volume and core distribution, but also in terms of services." That includes both "services to pharmaceutical companies around data aggregation and outcomes information," as well as "services to health systems and health plans as they expand into the [accountable care organizations] and insurance exchanges that are coming with health reform." It also includes "services to our patients in terms of being able to offer them more than just distribution," he said.
"It might be hospital readmission management," Hagerman said, "or some other form of ancillary patient care service like disease management that helps keep patients with complex therapy out of the hospital."
A resource for patients, prescribers and payers
Ask any of the roughly 900 people who work for Diplomat Specialty Pharmacy what the company is best known for, and you might get a variety of answers: creating a patient-centric, information-driven business model that merges effective clinical care and patient outcomes with lower costs for patients and payers; giving retail pharmacies the resources to compete in the specialty pharmacy arena; or boosting average patient adherence rates to 90% and above through effective management of patients, drug utilization data and out-of-pocket costs. But boiled down to its essence, the key question for Diplomat, said VP clinical services Gary Rice, is "how do we maximize the patient’s experience?"
"Persistency and compliance are just two of the surrogate markers of patient experience," Rice noted. "If we can create realistic goals and objectives for how those patients manage themselves through a particular drug treatment plan, and we’re helping them do that, there’s a much greater chance that the patient not only will stay on that med, but that the patient optimizes outcomes. And in the long run, everybody wins.
"Teams of pharmacists, patient care coordinators and insurance and funding specialists all work directly with patients to support them as they and their caregivers grapple with serious, often life-threatening conditions and drug regimens that often come with difficult side effects and high costs.
"We want our care coordinators to understand the journey these patients go through," said CEO Phil Hagerman. "How often do you think about breast cancer, and the fact that many of these women are debilitated for six to nine months during the treatment? What does that do to the mother who is a single-parent head of household who loses her job because she can’t go to work, she runs through all of her [financial benefits], and she eventually loses everything?"
For that reason, helping align patients with sources of funding and co-pay assistance to help allay their out-of-pocket costs has become a prime focus for Diplomat’s patient-support activities. As Robert Fleckenstein, VP operations, puts it: "If we can’t clear the financial barriers, the other services we offer patients fall by the wayside."
Thus, Diplomat employs a team of 15 funding specialists "focusing on doing nothing but working directly with the patient to facilitate those applications," said Stephanie Turnbull, director of patient access and member benefits management. Those 15 or so specialists saved thousands of patients roughly $19 million in direct out-of-pocket savings last year through non-profit organizations, and "that doesn’t include additional options … such as co-pay cards or manufacturer programs," she added.
"Patients don’t know that these funds are available," she said.
Diplomat’s funding team is composed of specialists in different disease states or therapies like cancer and immunology "because those specialists can focus on different sources of funding," Fleckenstein said.
"The key point is to be the facilitator, and to take as much burden off the patient and the prescriber as possible," Turnbull added. "We’re the coordinator between the prescriber, the insurance company, the [funding support] foundation and the patient — to be that central point to answer all those questions for the patient … instead of having to call five different people."
Diplomat’s service model even extends to suicide prevention counseling. That effort goes hand-in-hand, Hagerman said, with the ongoing management and monitoring of patients by the company’s patient care coordinators and pharmacists, including looking for signs of depression. "We do a lot of depression screening around our therapies, and we find depression to be a very serious problem with chronic illnesses like multiple sclerosis — especially around early diagnosis," he explained. "The early diagnosis of a serious chronic illness is one of the most challenging times the patient ever goes through."
Jennifer Cretu, VP information technology and marketing, says that the company’s homegrown software platform, eNAV (Electronic Navigator), provides the "underlying technology" that supports "a high-touch model and seamless patient experience."
Originally launched in 2008 to help guide Diplomat’s care specialists and clinical decision-making for patients with MS, eNAV’s workflow application now supports treatment applications for 20 disease states.
The goal, Cretu explained, "was to move away from managing patients with calendars and Excel spreadsheets. eNAV guides our patient care specialists through patient-specific care plans."
Those care plans, she added, "are driven by the system, and allow for the collection of patient demographics, historical adherence and surveys, refill assistance and clinical reporting."
Cretu called eNAV "essentially the legs for our company," allowing Diplomat to "take better care of our patients with complex diseases that have high costs," against a backdrop of increasing health regulations and REMS requirements. "We needed a system that was flexible enough to manage all those pieces and transfer data back to our pharma partners, prescribers and payers … to take better care of the patient," she said.