A longtime patient comes in for a follow-up, frustrated and exhausted. They’ve spent weeks battling with their insurance company over their specialty medication—only to be told it isn’t covered. The out-of-pocket cost? Almost $4,000 per month. They look at you, their trusted provider, and ask:
“What am I supposed to do now?”
Rising specialty drug costs aren’t just putting financial strain on patients; they’re disrupting medical practices, overloading staff, and making it harder to deliver high-quality care.
If you own a medical practice, these cost increases are more than just an economic trend—they’re an operational challenge that affects patient adherence, administrative workloads, and even your bottom line. Every prior authorization battle, every denied claim, every patient who delays or abandons treatment—these factors add up, creating financial risk and inefficiencies in your practice.
You can’t control pharmaceutical pricing. But you can control how your practice navigates these rising costs.
How Specialty Drug Costs Are Disrupting Independent Practices
Rising specialty drug prices don’t just affect patients—they create significant operational challenges for medical practices. Administrative workloads have ballooned, reimbursement policies have become more restrictive, and insurers are shifting more financial risk onto providers. These factors make it harder for independent practices to maintain efficiency and profitability while ensuring patients receive timely care.
Administrative Workload: The Prior Authorization Nightmare
Prior authorizations have become one of the biggest obstacles to delivering specialty drug treatments. As insurers tighten approval requirements, providers and staff spend more time navigating the complex, often frustrating PA process than ever.
How Prior Authorizations Are Draining Your Staff’s Time
The average medical practice spends nearly 15 hours per week on prior authorizations. That’s almost two full workdays lost to administrative tasks instead of patient care. Specialty drugs, in particular, require multiple rounds of approval, adding further complexity to an already time-consuming process.
Practices that administer biologics, infusions, or other high-cost specialty medications in-office face an even greater challenge. Insurers frequently demand step therapy protocols, requiring patients to “fail” on less expensive treatments before approving the specialty drug. In other cases, restrictive formularies force providers to resubmit documentation every few months—even when a patient has been stable on a medication for years.
The Hidden Impact on Patient Care
While PA requirements are intended to control costs, they often create dangerous delays in treatment. Patients waiting for insurer approval may go weeks or months without access to their prescribed medication. These disruptions can lead to worsening symptoms, disease progression, and even hospitalizations that could have been prevented with timely treatment.
Many patients become so discouraged by the process that they give up entirely. Studies show that when prior authorization requirements are too challenging to navigate, patients are significantly more likely to abandon their prescribed treatment altogether.
Administrative Burden and Burnout: A Growing Crisis
Beyond patient care, PA inefficiencies heavily impact your practice’s workflow. The constant need to follow up on approvals, correct denied claims, and navigate insurance appeals adds to staff burnout. Medical assistants, nurses, and administrative teams are stretched thin, forced to juggle patient care with endless insurance battles.
This workload is even harder to manage for independent practices without large administrative teams. Many small practices cannot afford to dedicate staff solely to handling PAs, leading to longer wait times, lower patient satisfaction, and growing frustration among providers and staff alike.
If prior authorization hurdles continue at this pace, independent practices, especially those without dedicated administrative support teams, will struggle to keep up.
How Your Practice Can Adapt and Stay Ahead
While you can’t change the rising cost of specialty drugs, you can proactively protect your practice, streamline operations, and support your patients. Here’s how:
1) Reduce Administrative Burden by Streamlining Prior Authorizations
One of the most effective ways to ease the burden on your practice is by implementing systems that speed up prior authorization approvals. If your staff is drowning in paperwork, it’s time to optimize the process.
Use Electronic Prior Authorization (ePA) Systems to Cut Processing Time
Many practices now use electronic prior authorization (ePA) systems, such as CoverMyMeds or Surescripts, which can automate submissions and reduce processing time by up to 70 percent. Instead of spending hours on the phone with insurers, these platforms handle real-time authorization requests, flag missing documentation, and reduce delays.
Assign a Prior Authorization Specialist to Improve Efficiency
If your practice handles a high volume of specialty medications, consider designating a PA specialist—someone on your team dedicated solely to managing authorization requests. This will prevent disruptions in patient care and ensure consistency in how approvals are handled.
Track PA Trends and Use Data to Negotiate with Payers
Tracking prior authorization trends can also be a powerful tool. If certain insurers or medications are repeatedly getting denied, document these patterns and bring them to payer contract negotiations. Sometimes, simply presenting data on how PA delays impact patient outcomes can push insurers to adjust their policies.
2) Strengthen Your Practice’s Financial Position Through Smarter Payer Negotiations
Independent practices often feel powerless in the face of insurance policies—but negotiation is possible, especially if you come to the table with data.
If you administer specialty drugs in-office, clarify your reimbursement structure with payers. Some insurers reimburse at ASP (Average Sales Price) + 6 percent, while others offer flat-fee payments. If you’re losing money on drug reimbursement delays, push for more transparent and predictable payment models.
Another key negotiation point? Formulary flexibility. If your practice sees consistent denials for a certain specialty drug, you may be able to negotiate lower PA requirements for that medication—especially if you can demonstrate that denials are leading to higher long-term healthcare costs for the insurer.
The key to successful payer negotiations is data. Track how much time your staff spends on denials, how many patients face treatment interruptions, and how many appeals are required per medication. The more quantifiable evidence you can provide, the stronger your negotiating position.
3) Help Patients Access Affordable Specialty Medications
Your patients rely on you for medical care and look to you for guidance in navigating the confusing world of drug pricing. You can improve adherence, retention, and outcomes by proactively connecting patients with financial assistance programs.
Many pharmaceutical manufacturers offer copay assistance programs, but patients often don’t know these exist. Consider having a dedicated staff member or resource guide available to help patients find:
- Manufacturer patient assistance programs (PAPs)
- State and nonprofit drug cost relief programs
- Independent charitable foundations that cover specialty drug expenses
Additionally, exploring this option can drastically lower costs for uninsured and underinsured patients if your practice is eligible for 340B drug pricing through an FQHC or hospital partnership.
The more financial resources you provide, the better your patients’ chances of staying on therapy—and staying with your practice.
Final Thoughts: How Independent Practices Can Take Control
The rising cost of specialty drugs isn’t just a pharmaceutical industry issue—it’s a day-to-day operational challenge for independent medical practices.
The key to protecting your practice and supporting your patients lies in:
- Optimizing prior authorization workflows to reduce administrative waste
- Negotiating smarter with payers to secure better reimbursement terms
- Helping patients access financial assistance to improve adherence
Specialty drug prices may continue to rise, but your practice doesn’t have to absorb the full impact. By taking strategic action today, you can ensure your business remains financially strong while providing the best possible care to your patients.
Remy Healthcare helps practices navigate the financial and administrative challenges of specialty drug costs. From streamlining prior authorizations to improving payer negotiations, we provide the solutions you need to protect your bottom line and keep patients on therapy. Get in touch with our team today to learn how we can support your practice!