Why Patient-Reported Outcomes are Key in Specialty Pharmacy

Raking in about 50 percent of all pharmacy costs for only about 2.5 percent of all prescribed patients, the specialty pharmacy arena is one ripe for the development and use of patient-reported outcomes to assess treatment efficacy, according to Sree Chaguturu, MD, the chief medical officer for CVS Caremark.

As opposed to traditional clinical quality measures, which look at the provider-facing outcomes of care or the process of administering that care, patient-reported outcomes (PROs) measure how a patient feels as a result of the treatment they received. Did that surgery make it easier to carry in the groceries? Can the patient now walk a few city blocks?

This is a bit of a passion area for Chaguturu, who in his role at CVS Caremark is working to collect PROs to help patients, their providers, their payers, and their specialty pharmacists understand whether a specialty drug is working the way it should. After all, why pay thousands of dollars for a medication that isn’t even working?

That’s the way it’s been in the specialty pharmacy space for some time. That segment of the pharmacy industry is different from what most patients access, Chaguturu explained. Most people visit their local pharmacies to get small molecule drugs, or the pills that most take to treat common acute or chronic illness.

There’s also the mail order industry, which delivers small molecule drugs to patients’ doorsteps, and compounding pharmacies, which can take a pill and modify it for a special purpose, like turning it into a liquid for a kid who can’t yet swallow a pill.

But in the specialty pharmacy space, patients aren’t getting those small molecule drugs; they are getting medication via injections and infusions, and that adds a steep layer of complexity.

“Specialty pharmacy is a pharmacy that is designed to handle complex medications with specific handling and shipping requirements,” Chaguturu explained in a PatientEngagementHIT interview.

“Because they come in those injections or infusions, they have special handling requirements and shipping requirements,” he continued. “A lot of times specialty pharmacies need to ship medications and store them in very specific temperature ranges. As you could imagine, specialty medications, given the complexity of them, require different pharmacy to manage them than non-specialty medications.”

And that complexity comes at a high price—literally. According to 2021 figures from AARP, the average sticker price for a specialty drug came in at just over $84,000, a cripplingly high price that ups the stakes of these treatments. Patients, providers, payers, and specialty pharmacists alike want to know that the treatment actually works if they are to continue ponying up those large sums of money, Chaguturu stated.

Of course, there are a lot of ways healthcare measures clinical outcomes. Depending on the disease, there are physical markers that can signal a specialty drug’s success at improving health and wellness, Chaguturu explained. Take rheumatoid arthritis as an example.

“We can check rheumatoid factor to see if you have rheumatoid arthritis, that's a lab test,” Chaguturu pointed out. “But once we start you on medications, we really need to ask you as a patient, what is your joint pain symptoms? And are they improving? How often are you having flares? And how long has it been since you've had your last flare? How is it impacting your activities at daily living?”

“By understanding the responses to those patient-reported outcomes, we can determine if this medication working for the patient or if we should be helping them figure out what the right treatment plan is,” he explained.

PROs are something CVS Caremark is building out as a part of its digital patient engagement and medication management system in specialty pharmacy. Using a combination of wearable technology and patient surveying, Chaguturu said CVS Caremark hopes to establish a benchmark understanding of how a patient fitting certain characteristics feel after using a specialty drug.

For example, CVS Caremark can sift through patient-generated health data (PGHD) gleaned from devices like smartwatches or other wearable trackers that signal how a patient is responding to therapy in her everyday life. In a wearable program for patients with neurologic disorders, wearable fitness bands helped CVS Caremark assess how a complementary fitness program supported specialty drug efficacy, Chaguturu reported as an example.

CVS Caremark and a payer partner hypothesized that a patient engagement and wellness program could support, and potentially supplement, some of the specialty medication used to treat patients with this neurologic disorder. By using PGHD and PROs collected through the wearable sensors, the pair were able to see success.

That data helped CVS Caremark and payer partners both improve patient outcomes while cutting $55 in medical cost per patient.

Chaguturu said adding in surveying for PROs would enhance those efforts. Harkening back to the example about rheumatoid arthritis, the CMO said PRO surveying helps measure patient pain after using specialty drugs.

“And by tracking, when do you get your medications and what's your dosing and how are you responding to therapy, we can better understand is a patient responding to therapy,” he stated.

Chaguturu and his team at CVS Caremark hope to build out a broad enough PRO repository to be able to determine a typical response to a medication.

“As we develop this out further, we'll be able to collect enough data that allows us to say, ‘well, patients like you tend to see a response in a certain number of weeks, and if you still haven't responded, then we can follow up with you on what's the right next step.”

Ultimately, that approach should help bend a cost curve that has made access to care challenging for seriously ill patients. A patient might not necessarily stick to a medication that isn’t working, especially if its specialty pharmacy knows what a typical response should be.

CVS Caremark is working to integrate this into its current digital engagement platforms as part of its specialty pharmacy offerings, and so far it’s been successful, Chaguturu said.

“We're really excited about the ability to over time provide individualized therapy goals on activities or treatment objectives through digital engagement,” he concluded. “We are engaged with 85 percent of our patients digitally and we have sent out 25 million outbound messages in 2020. We have the foundations to really build upon patient generated data, patient reported outcomes to improve pharmacy care.”