To the Editor:

I read the article, “It’s Time To Stop Fighting Specialty Pharmacy,” by Bonnie Kirschenbaum (February, page 26), and found it appalling that the author chose to have such a limited focus and apparently a lack of understanding of the implications associated with the current path that some insurance companies and manufacturers are taking in regard to specialty pharmacy.

First, I would be interested in understanding Ms. Kirschenbaum’s thoughts of how the current path of specialty pharmacy will affect hospital revenue; after all, her standing column, “Reimbursement Matters,” implies that she is an expert on reimbursement issues, and yet she chose not to address that angle in her column. Second, I would be interested in the author’s views on who should determine which pharmacies/pharmacist can or cannot buy limited-distribution drugs. It is my understanding that state boards of pharmacy have the authority to determine whether a specific pharmacy is licensed or not and which pharmacists are qualified to purchase, inventory and dispense drugs. It appears that this new approach—allowing manufacturers and insurance companies to make those decisions—is more in line with protecting the corporate entity rather than protecting public interest.

I am also finding it difficult to understand how an insurance company can mandate where a patient gets his or her prescriptions filled when there are state laws that prohibit others from directing patients to specific pharmacies. I do agree with the author’s concern about patient care, but I think she totally misses the obvious differences between the motivation of health-system pharmacists (providers) and for-profit entities (manufacturers and insurance companies).

The other obvious point that Ms. Kirschenbaum fails to address is that affordable care must begin with affordable drugs and equipment and that specialty pharmacy initiatives are more about protecting manufacturers’ investment in research and development than in ensuring that care is affordable and accessible. After all, what good is it to have specialty pharmaceuticals if no one can afford to pay for them?

In addition, health-system pharmacists have been successfully delivering specialty care with complex drugs for years and are proficient in acquiring, storing, dispensing and monitoring sophisticated drug therapies (i.e., heparin, colony stimulating drugs, etc.). Wouldn’t it be more affordable and prudent to use existing delivery channels that work than to create limited-distribution channels that fragment the continuity of care and prevent providers from participating?

Perhaps a more appropriate focus would have been to describe the merits of allowing qualified health-system pharmacists to participate in limited-distribution and specialty pharmacy supply channels similar to what is being proposed by the UHC Specialty Pharmacy Collaborative.

I don’t know what motivated Ms. Kirschenbaum to write—and you to publish—such an unbalanced article, but it appears that you both are out of touch when it comes to this topic.

Steven Ciullo, BPharm, MS, MPS
Syracuse, NY

Editor’s note: To Mr. Ciullo’s point regarding the UHC Specialty Pharmacy Collaborative, Pharmacy Practice News covered the initiative in a previous issue: “Specialty Pharm Carve-out May Be Eased by UHC Plan” (November 2013, page 1). In that same issue, we also explored some of the downsides to specialty pharmacy: “White Bagging of Specialty Drugs Draws Some Ire” (page 36). We feel these articles presented a balanced treatment of the topic in our reporting. It’s also worth pointing out that Ms. Kirschenbaum is a columnist, not a reporter, and thus is free—indeed encouraged—to inject her own views into her work.

Ms. Kirschenbaum responds:


The past few columns have been written to address or bring to the table many bewildering issues that are facing hospital pharmacy practitioners and often putting them into unfamiliar and uncomfortable territory. Certainly there’s angst in the pharmacy when the hospital is moving ahead with new models, and specialty pharmacy is no exception. The tremendous expense of new drugs for the patient, the practice site and the payer’s concerns over cost control have ramped up discussions of how to handle this growing market force. However, rejecting change and clinging to past practices may not be the prudent thing to do in a health care environment that is charging ahead.

There’s no question that the phrases “specialty pharmacy” or “white bagging” or “brown bagging” will stir up emotions and a myriad of comments and opinions. And yet some larger multi-facility organizations or teaching facilities have opted to establish a specialty pharmacy within their organizations to service their patients. Others have vetted specific specialty pharmacies with whom they work when necessary. Granted, still others have chosen not to play in this field at all or are dreading change.

I’m not suggesting that any one of these responses is necessarily the “best” strategy for dealing with this market trend; that’s a decision each hospital or health system has to make on its own. But the reality is that specialty pharmacy, specialty pharmaceuticals and restricted drug distributions systems, play a major and ever-expanding role in the management of health care dollars spent on medications. The hospital pharmacy or ambulatory care practitioner needs to recognize this dizzying degree of change and decide how to play in the newly designed sandbox.

Of course, it’s the patients and their needs that must come first!