Specialty Drugs and Preferred Pharmacy Networks in Canada
In the most recent episode of Downton Abbey (empathy watch with my wife and because the latest season of Trailer Park Boys isn’t out yet), the crusty veteran village doctor mentions the discovery of insulin and how a diabetes diagnosis “might no longer be a death sentence”. Nice call out to Frederick Banting, and that was less than 100 years ago. Made me think about the modern equivalent …. and no doubt it is specialty drugs like Sovaldi and Viekera Pak that render hepatitis C “no longer a death sentence”. This then took me to the battle in the US between CVS Health and Express Scripts as to which of these two innovative drugs their respective plan members should get, at what price, and from which pharmacy.
But first let’s get back to Canada. So you’ve just been prescribed a statin to help with the treatment of your high cholesterol – welcome to the club. Unless your drug plan tricks you up, you trundle down to the retail pharmacy of your choice and get your prescription filled with the confidence that the pharmacist you have dealt with for years is providing you with patient-centric advice on your entire drug regimen and a personalized cost-benefit choice on whether you should get brand or generic.
Now enter the world of preferred pharmacy networks (PPNs), which has been going on in the US for years now but is really just starting to find its legs in Canada. In this case, your private drug plan has done a deal with a particular drug store chain (or if you are lucky, more than one chain) that results in possibly an incentive, like a lower co-pay, for you to get your drugs at a store in that PPN. There is also likely a penalty or disincentive (best case a higher co-pay but worst case no coverage at all) if you really want to go to a pharmacy outside of the PPN. I’m going to guess that your premiums did not go down for this “feature” of loss of choice. Interestingly, studies have repeatedly shown that as consumers, a higher or lower co-pay will not cause us to change pharmacies. Adherence is very much influenced by the continuity of care we get from staying with one pharmacy.
But PPNs and primary care drugs is not what this post is about. Let me go back to specialty drugs. Specialty drugs dominate the innovation pipeline. There’s not a lot going on in the statin world, but there are plenty of new drugs coming out of the pipeline for Multiple Sclerosis, Hepatitis, and a myriad of orphan diseases. The recently released New Drug Pipeline Monitor from the Patented Medicines Price Review Board is pretty revealing in terms of how specialty drugs are staring to dominate. According to an analysis of private claims in 2013, specialty drugs clocked in at almost 25% of the total spend but only 1% of the total claims. The average annual cost of a specialty drug per patient is in the $20,000 range. This is serious business. This also explains Shire’s purchase of NPS Pharmaceuticals.
So now you’ve been diagnosed with an inflammatory condition or maybe multiple sclerosis (MS). I’m going to focus on MS because I have first hand experience there and know all the drug names – but I think the patient experience with respect to prescription drugs is the same for other specialty conditions.
Old school specialty drugs were probably infused so where you got your drug from was a mystery – it just showed up at the infusion clinic. You didn’t realize that the drug was dispensed from a McKesson or an AmerisourceBergen. However, current and next generation specialty drugs are often self-injectable or orals (aka pills). You should be able to get those from the same retail pharmacy you use for your primary care drugs, right? It might surprise you that the pharmacy market leaders for specialty drugs are: McKesson, Innomar/AmerisourceBergen Specialty, Bioscript, Shoppers Specialty Health, and Bayshore. What’s the likelihood that you have one of these in your neighbourhood? In the US, Express Scripts Specialty Benefit Services dominates the specialty drug market with a home delivery service.
Why does this happen? Re-enter our good friend the PPN. PPNs come about for many reasons. They might come from your private insurance provider, like the Sun Life Preferred Pharmacy Network that was formed with McKesson. They might come out of the drug manufacturer who has a patient assistance program that pushes you to a specific pharmacy. They might also be because you live in Nova Scotia (more on that two paragraphs down). The other legitimate reason is, quite honestly, retail pharmacy has not stepped up to serve the specialty market as that is harder to do so and may require cold chain facilities as well as extra knowledge and support. Self-injectables come with proprietary injection devices and require other supplies like needles. Plus the devices break so the pharmacy needs to be able to handle repair and returns. I am surprised though at the number of times I’ve heard from independent pharmacy owners that they can’t make money with specialty drugs. I’ve never heard that from a Porsche or BMW dealership. Nordstrom figured out how to serve a high-spending customer a long time ago.
Generally, a PPN is not good for patient-centric care as it drives a wedge between the pharmacy care you get from your primary care pharmacy and the care you get from your specialty pharmacy. This is even more important when you consider that over 70% of specialty patients also suffer from one or more chronic condition. Just because you have MS, you are not immune from high cholesterol or high blood pressure. The world is not that fair. It also takes choice out of the hands of the patient which tends to disempower and disengage them. Imagine how you’d feel if you were told that there is only one restaurant you can eat at and it has terrible hours and is a 90 minute drive away.
In my case, I am on Rebif, a disease modifying therapy (DMT) for my relapsing-remitting MS. Rebif is a self-injectable and as I live in Nova Scotia, also happens to be covered by a special program under the provincial Pharmacare program. Given the freakishly high rates of MS in Nova Scotia, that is a good move on the behalf of the government. Where it gets weird is how I get my Rebif. The Nova Scotia government has established a PPN for MS drugs that happens to be the “2 North Pharmacy” in the QEII hospital in Halifax. I challenge you to find it. Even the lovely navigator at the entrance of the hospital didn’t know where it was the first time I went. Having found it, I now affectionately call it the Skate Sharpening window. If you’ve ever been in any arena in Canada, you’ll get that visual. It could be worse. If I didn’t live in Halifax and have the ability to come down and pick my prescription up, I would have to have it shipped to me by bus via my local gas station for an additional fee.
I get my Rebif from “the booth” but have no relationship with any pharmacists there. Not sure I’ve ever spoken with one. They just hand me my drugs in a brown paper bag kind of like back in high school. The flip side is that my local pharmacist, from whom I get my cholesterol drugs as well as drugs related to my MS, genuinely cares about and engages me on my health but forgets that I am on Rebif (not in their system) and forgets that I have MS and certainly doesn’t engage me on adherence and side effects on my most important and most expensive drug.
As I now consider changing my DMT to one of the new oral MS drugs, I hope that ends up with me dealing with one pharmacy of my choice. It’s time for retail pharmacy in Canada to step up to make that happen to the benefit of the patient. This is the future of prescription drugs so I’m sure there’s a way to make money at that as well. Maybe they could speak with someone at Nordstrom (and not Target). For pharmaceutical companies bringing these specialty drugs to market, it seems to me that treating them as a health care service instead of a drug sale is the right way to go and would then lead to including retail pharmacy somehow as part of the total patient care. That would result in positive things like a pharmacist engaging the patient in adherence resulting in more revenue for pharmacy and pharma and reduced overall healthcare costs. Win-win-win.