Why Specialty Drugs Dominate Spending, and the Frontline Roles Shaping Patient Access

Megan Wetzel, the VP of product, access, and affordability at CoverMyMeds, is well-versed in the product management, hub solutions, and affordability spaces. Drawing from her decade-plus of experience, she sat down with Pharma Commerce to discuss how specialty drugs continue to account for a disproportionate share of US drug spending, despite representing only a small percentage of prescriptions.

Several key factors contribute to this imbalance, and chief among them are the complexity, cost, and specificity of specialty therapies.

Unlike traditional retail drugs, Wetzel notes, specialty medications are designed to treat serious, chronic, or rare conditions and often require specialized handling, monitoring, and administration. Many of these treatments must be administered in clinical settings such as hospitals or physicians’ offices rather than through retail pharmacies. These requirements add layers of logistical and operational costs throughout the treatment process.

Ultimately, the imbalance stems from the intricate science, individualized care, and high economic stakes behind specialty medicines, factors that will only grow more prominent as healthcare becomes increasingly specialized and patient-centric.

In the following Q&A, Wetzel also dives into the role of field reimbursement managers in helping patients access specialty drugs; considerations that should guide insourcing, outsourcing, or adopting a hybrid model for field reimbursement support; and much more.

Pharmaceutical Commerce: How are prior authorizations and claim denials affecting patient care and provider workflows? Alongside that, how does patient loneliness directly undermine adherence and outcomes?

Megan Wetzel: It's a huge issue. Barriers have a profound impact on providers and a huge impact on patients. For patients, every time you have a delay in a prior authorization or just a claim denial in general, that typically leads to a missed dose or you abandon therapy altogether, which worsen health outcomes when you don't take your therapy.

In general, anytime you experience some sort of barrier, you have that risk of not overcoming that barrier, which means that nearly 50% of patients when they get a barrier of affordability, abandon therapy. So 50% of patients, when they experience an out-of-pocket cost that was over $125, abandon that therapy altogether. Those types of prior authorizations, claim denials, and affordability barriers really do impact patients in a very large way.

For providers, we saw that 95% reported difficulty starting patients on therapy. Especially when we're thinking about specialty therapies; it's just a lot of administration work.

This often involves multiple screens, and clicking on a lot of documentation. They're working on appeals—anytime they don't go to get that claim acceptance right off the bat, it typically just delays them in getting a patient on
therapy altogether.

This is really an overall systematic strain—and these issues reflect an overall fragmented system. Anytime that you experience these kinds of delays in care delivery, it just erodes the trust that we see between patients and their care team as well. Patients are less likely to believe that they can get on these therapies, and they're less likely to trust their providers. Overall, it just slows everything down, and creates friction in the overall system.

PC: What underlying market or access factors are contributing to the disproportionate spending on specialty drugs?

Wetzel: It’s a great question. It's one we hear all the time as well, and, honestly, there's a couple of different factors that play into it. Specialty medications are incredibly powerful, but they're also very, very complex. They're designed really to treat those serious chronic conditions, and that means they come with very high development costs. They have very rigorous—even more so than traditional retail drugs—approval processes, and they really require specialized care.

Sometimes they're administered in the doctor's office, sometimes they're administered in a hospital setting. It's not just something you typically can pick up at your retail store.

We do have a couple of stats that I wanted to share around the complexities of specialty medications.

They actually made up 93% of the US drug launches in 2024, which, to your point, despite having a much smaller share of total prescriptions, the number of drug launches around specialty has been quite high. Also to your point, there's a bit of an imbalance there, and that imbalance is from several factors and, like I said, very high R&D investment. Biopharma R&D reached over $100 billion in 2024, a 44% increase over the previous year. Much of that R&D has been directed toward specialty therapies, which is exciting in our world.

You want to see those specialty, complex chronic conditions get the attention that they need, but it requires much longer R&D times and much more spend. They typically treat a much smaller number of patients, given their complexity of the therapies. The complexity of treatment is really personalized, too, when it comes to administration; so it's not really a one-size-fits-all.

When we're talking about multiple patients that can take that therapy, you typically have to monitor that patient. It's administered in a different setting most of the time. It's probably not something you can administer yourself. This, again, increases that overall cost that it takes to [even] think about specialty meds.

I'd also just like to point out that these therapies typically launch with premium pricing. Because they're so high when it comes to R&D investment, you also have to think about the pricing that comes with these specialty medications.

Not every patient only has this condition, but not every patient can afford these therapies. It’s very limited competition. It's very specific to the therapy that comes to market, but overall, we know that there's going to be a growing need for these medications. We know that we've got a growing aging population and, thus, a rise in these chronic conditions.

We expect by the end of this year that the number of Americans 65 and older is expected to rise to 63 million, which is a 9% increase over 2022; and we also expect that by 2050, it'll surge to 82 million.

We know that these specialty medications and these chronic conditions are going to continue to rise, but typically, it's because these medications target very complex conditions for very specific therapies, and so you see a smaller patient population. But, again, they're more complex in nature when it comes to R&D.

PC: Field reimbursement managers often work behind the scenes. Can you describe what their day-to-day role looks like in helping patients access specialty medications?

Wetzel: Field reimbursement managers (FRMs) really play an important role in supporting the providers’ offices. Their day-to-day is really focused on education. They educate the care team, so they go into these provider offices and really educate them on how to navigate some of these complex payer requirements, how to think through the PA requirements, and the processes that go along with that with specialty meds, specifically, too, concerning claim denials and how to overcome some of those.

They're really trying to help the offices understand what's needed and then how to approach it differently and more efficiently in the future.

They also use tools like FieldConnect, which is a real-time data source that they can bring into the conversation. It allows them to have conversations around coverage insights, so they can be a little bit more proactive about, "here's what the coverage may look like."

It also talks about denial trends, so they can educate the providers around, "here's some of the trends we're seeing in denials in this specific space." The idea is that the offices are making much more informed decisions. It's kind of a mix a little bit of their technical know-how, and then just more of the strategic guidance that they can share with some of these care teams and the provider offices.

They're trying to make sure that they've got the information and the resources they need to get patients through these barriers more effectively, but especially in specialty medications, because we know that these journeys are much more complex. We're seeing that these FRM teams are much more helpful and supportive when thinking about these complex patient journeys.

PC: What are the main considerations that should help guide organizations that are weighing whether to insource, outsource, or adopt a hybrid model for field reimbursement support?

Wetzel: It really comes down to flexibility and fit. I do think it's dependent on that specific biopharma company's needs. That specific biopharma’s circumstances depend on what the in-house sales team currently looks like. What are they currently supporting? Do you have the resources that you need in-house to extend that education and support in the field? Is that something that you need from an outsourced vendor?

I think the key, though, is that you really want a model that integrates well with the provider workflow; so thinking about how you can give those field teams the data that they need to provide the most information that they can when they're in the field in those provider offices.

I think some of those hybrid models are really gaining traction because you're seeing these typical sales teams then getting paired with these data-focused field teams that are out there really educating about specific denial analysis or specific friction points, because they've got tools from some of these outsourced vendors in this space.

I think it just comes down to a specific fit for that manufacturer and maybe that brand or that therapeutic area—if their sales teams are educated enough to have those conversations. Sometimes, they need that additional data that can come from an outsourced vendor.

But ultimately, you want a model that fits however it's going to be easiest to get that patient on therapy, depending on what your coverage barriers may be and what your process barriers may be.

The goal is to get that field team as educated as possible around those problems.