Health Systems

Specialty Pharmacy Strategy

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How health systems can enhance patient care and drive outcomes.

April 02, 2015

In this climate of value-based payment models and measuring quality care, pharmacists are more responsible than ever for driving patient outcomes. And it's outcomes that will enable success as value-based contracting grows; however, as more and more treatments for rare and costly disease states emerge, it can be difficult to ensure quality care throughout the patient journey.

One way health systems can drive outcomes and improve treatment for patients with complex diseases is with a specialty pharmacy strategy. Implementing a specialty pharmacy strategy can leverage the health system pharmacists' focus on medication to create additional value for patients and capture cost savings by filling the gap where traditional retail pharmacies are not equipped to manage the treatment journey. How should health systems approach the development of a specialty pharmacy strategy? Getting started requires an understanding of the benefits, models and challenges associated with specialty pharmacy in the health system environment.

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Benefits
Overall, a specialty pharmacy strategy can help overcome the delays in therapy presented by outsourced benefits administration and physician white-bagging/brown-bagging. Defining a specialty pharmacy strategy is also a way to establish processes for streamlining communication and counseling with in-house clinical pharmacists and ensure ongoing treatment monitoring to reduce readmissions and manage side effects.

As part of strategic planning around specialty pharmacy, health systems should explore ways to drive outcomes by building in programs that leverage specialty drug expertise and care coordination. There are two key areas where the health system can make significant strides in accomplishing organizational goals while enhancing patient care:

  • Adherence and compliance programs. Removing barriers that prevent medication adherence reduces both readmissions and associated penalties while improving outcomes. Adherence-related initiatives on the health systems side can include bedside concierge, 24/7 call centers for disease- and medication-related patient support and other transitional care offerings that combat poor care transitions. In addition, disease management services can help patients manage side effects - a critical component in the success of specialty therapies.
  • Patient education/counseling. Education is a critical step in preventing both access barriers related to speed to therapy/uptake and medication non-adherence, especially as it relates to complex therapies and disease states. Partnering with manufacturers to leverage patient support programs can improve outcomes. The types of support offered can range from coordinated follow-up and call centers to co-pay assistance. In addition, particularly as it relates to ensuring medication safety, taking advantage of the educational materials provided as part of manufacturers' Risk Evaluation and Mitigation Strategy (REMS) program can also be important in avoiding medication-related injuries and dangerous side effects.

A specialty pharmacy strategy can enable a health system to: 
• Support transitions of care
• Embrace value-based care with payers


Specialty pharmacy challenges
Models for implementing a specialty pharmacy vary, and there are unique challenges associated with specialty pharmacy that bear consideration and mitigation. Product access can present significant obstacles, especially in light of limited distribution drugs/closed distribution and price pressures associated with specialty therapies.

For health systems that choose to implement a specialty pharmacy strategy, accreditation is a complex process that requires a documented strategy and mission, as well as a review of processes and procedures, with carefully weighted evaluations defined by the accreditation organization. It's a daunting process that demands both time and resources, but accreditation can optimize specialty pharmacy processes to improve both operations and regulatory compliance.

In thinking about resources, health systems also need to consider whether existing staff can absorb the payer access, benefits verification and other patient support needs that specialty pharmacy creates. Part of defining the strategy will be determining staffing needs and organizational capabilities, along with how to effectively share data across organizations, none of which can compromise resources from the patient floor.

Goal planning and service model decisions
A significant decision, and perhaps one of the most important components of the specialty pharmacy strategy, will be how the health system will actually coordinate dispensing. Will medications be patient- or provider-administered? As part of the decision-making process, health systems must consider the goals they want specialty pharmacy services to help them achieve. Is the specialty pharmacy strategy aimed at capturing a defined percentage of prescriptions? If so, projecting the budget, spend and revenue will be critical, as will designing the service model with PBMs and payers in mind.

Building an in-house specialty pharmacy, while certainly beneficial, does not have to be the only path for implementing a strategy. Whether in-house or outsourced, the aim of specialty pharmacy should be addressing the needs of patients requiring specialty therapies. As such, either model should ensure that patients have access to a central hub to ensure easy access to therapy.

When deciding to partner with an outsourced specialty pharmacy, one of the most important choices the health system should make is whether it will outsource direct-to-patient dispensing for all disease states or select therapies only. Disease states that are difficult to manage or require wraparound services and support call for scaling internal offerings or partnering for seamless care transitions. Therapies such as IVIG, which requires home health/nursing coordination, or oncolytics with limited distribution and additional touch points are those the health system may want to start internalizing. And insourcing dispensing for disease states that demand more long-term care - Multiple Sclerosis and autoimmune disorders, for example - can be part of a strategy for adding value throughout the therapy journey. 

As such, in decision-making around implementation models, health systems should strategically decide what part of the care continuum they want to "own." Will the specialty pharmacy strategy include complete case management or partial integration with outpatient pharmacy to manage patient volume and workflow? What services will the specialty pharmacy team provide? Models for implementation can range from end-to-end services that cover benefits verification and prior authorization, with nurse- and physician-staffed call centers for therapeutic support, or supplementary support that integrates with mail order and outpatient retail pharmacy. The key will be defining what the health system wants to accomplish and integrating the programs and elements that best meet those goals.

The value of partnership
Partnering across the continuum means leveraging the right relationships to best serve patients and deliver value. And partnership is what the specialty pharmacy strategy should be all about - aligning the right health system services with overall goals and integrating the right players across the care delivery model.

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