Paula Bickley, Vice President, Market Access, Biologics by McKesson

Technology-driven innovations in care delivery grew rapidly in response to the pandemic, and none expanded faster than telehealth. As the need grew for new channels of safe, easily accessible care delivery, federal stimulus packages were enacted to support telehealth.

This legislation, passed in March 2020, enabled the Centers for Medicare & Medicaid Services (CMS) to make changes in telehealth policies, and many commercial payers instituted similar guidelines. Under the new regulations, providers can treat both existing and new patients virtually while being reimbursed at the same or close to the same rate as providers would be for in-office visits.

With relaxed regulations, telehealth grew dramatically as more and more providers embraced the technology. In the second quarter of 2020, virtual encounters comprised 14% of all health care visits.

Telehealth in oncology also grew. Prepandemic, only 8% of oncologists/hematologists in a recent survey reported using telehealth, but by May 2020, that number skyrocketed to 88%; 90% of oncologists/hematologists also indicated they plan to keep using telehealth postpandemic.

Telehealth is clearly here to stay, but to realize its vast potential, key stakeholders must support this care delivery channel and recognize its benefits. A look at the telehealth care delivery model over time in the specialty pharmacy context, as well as what can be done to sustain the advances made in telehealth, will be instrumental in this regard.

Lastly, the divide between medical and pharmacy benefit plans must be addressed. Health care is delivered in a variety of silos, and it is often said clinical care is a combination of many silos—each standing alone, doing what it does best.

 A patient’s medical plan is a separate silo facilitating medical services, and another silo, a pharmacy plan, manages access to drugs.

This separation increases the challenge of aligning the plans to allow for telehealth visits and guaranteed telehealth access to centers of excellence. To advance technology-driven channels of care, medical and pharmacy plans must concur on all aspects of coverage for telehealth medicine.

Can Telehealth Deliver High Quality Care?

Obviously, telehealth encounters will never completely replace face-to-face visits, but in some circumstances, they can actually drive improved patient outcomes. For instance, recent research found patients with cancer who could report symptoms on a regular facilitated call to a nurse in a telehealth visit or to a digital symptom-reporting portal lived 5 months longer on average than patients in the control group who were only able to report symptoms in a face-to-face clinical visit. 

Access to telehealth options allowed more responsive care in real time, resulting in improved symptom control that helped patients maintain mobility, a factor associated with better survival.

Although telehealth might be an acceptable care delivery mechanism when in-office visits are unsafe, some wonder if it should still play a role in health care postpandemic. Assessments of available data have resulted in a resounding yes, and a quick look at specialty pharmacy will demonstrate why—as specialty pharmacies use telehealth to drive and support quality care every day.

Specialty pharmacies have been providing superior care via telehealth long before the pandemic. In fact, experience has shown specialty pharmacies are highly efficient. 

Specialty pharmacies are experts in providing telehealth services because all their communication with patients is done by phone, text, and increasingly through online video channels. Consequently, specialty pharmacies have honed the ability to understand patients, communicate effectively with them, and efficiently manage their care without ever seeing them in person.

Specialty pharmacies position patients for success via telehealth encounters by creating and executing a personalized care path that supports adherence, reduces adverse events (AEs), enhances quality of life, and drives optimal outcomes.

Each patient is assigned a care team that is available by phone 24/7 and includes a board-certified pharmacist, a registered nurse, and, often, a certified pharmacy technician. With a dedicated team of experts, patients can request to talk to the same people every time, which helps build trust.

Members of the care team develop personalized assessments, adherence-risk evaluations, and ongoing counseling plans. Nurses constantly evaluate patients’ needs during regular check-ins over the phone, offering advice for AEs while coaching patients through any difficulties. Assessments are sent to the prescribing physician, indicating whether further action is needed or whether the patient was simply educated and assessed.

This care model—delivered entirely through telehealth mechanisms—is more scalable than in-office visits, allowing more patients to be seen and for longer visits. Specifically designed to enable frequent and consistent communication with patients, specialty pharmacy care models can serve to minimize logistical barriers, nonadherence, and unnecessary testing and medical services, which can result in reduced adversity and lower costs for all stakeholders.

Payers generally have accepted telehealth during the pandemic because they recognize it is a lower cost, highly effective form of care. Even Medicare has gotten on board with telehealth by waiving prior restrictions so more providers can deliver telehealth.

Currently, Medicare is assessing whether to reimburse clinical interactions via telehealth and electronic symptom-reporting portals. Payers have adopted telehealth much faster than anticipated due to the pandemic, but over time, they will likely also develop robust policies governing when telehealth visits are appropriate.

For specialty pharmacy, there are immense limitations on payer reimbursement, especially for patients with cancer or complex diseases needing interventions that were not previously possible with telehealth. Most payers have been slow to create guidelines that allow for reimbursement of telehealth services, often called medication therapy management. During the pandemic, many payers, especially CMS, relaxed the stringent requirements, although it is still quite challenging to qualify for and be paid for telehealth services.

However, there is great opportunity where specialty pharmacy excels, such as in monitoring AEs and providing adherence coaching between physician visits. Payers are recognizing how specialty pharmacy utilizes telehealth to help patients comply with treatment, reduce unnecessary care services, and optimize outcomes. 

But there is more work to do. Specialty pharmacy needs to educate payers so that they better understand how these benefits provide value to patients and the plans that are paying for these services.

Several obstacles must be overcome for telehealth to continue to thrive in the future. The pandemic highlighted the lack of digital infrastructure that plagues certain geographic regions; vast regional differences emerged among providers in relation to their ability to utilize technological platforms.

To ensure the future of telehealth and other virtual channels, policymakers must support broadband investments in underserved areas. Even if providers can offer telehealth, many patients lack internet access and need reliable broadband internet, if not in their own home, then through a regional technology hub.

Policymakers must also recognize patients with cancer and other complex diseases who would benefit from access to academic medical centers via telehealth for diagnosis, treatment planning, and care coordination with local providers. Collaborating with these centers can make possible the best opportunity for an optimal outcome, as these facilities bring cutting-edge treatments to patients. 

Quality care can be greatly advanced by requiring that access to centers of excellence through telehealth be written into coverage plans as a core benefit. Payers and policymakers must agree on these issues if real progress is to be made.

Telehealth has grown tremendously during the pandemic, demonstrating it can efficiently provide safe, real-time access to specialized clinical care. Medical providers who converted to telehealth are realizing the value of this technological platform because they are still able to provide a high level of care in a very challenging environment.

It is rewarding for the specialty pharmacy industry—experts in telehealth—to see providers adopting a patient-engagement technique that specialty pharmacy has successfully used for decades. Providers are recognizing what specialty pharmacy has always known: Telehealth empowers superior, cost-effective care by highly trained clinicians, driving optimal outcomes and a better patient experience.

Royce TJ, Sanoff HK, Rewari A. Telemedicine for cancer care in the time of COVID-19. 

. 2020;6(11):1698-1699. doi:10.1001/jamaoncol.2020.2684

Japinga M, Paff M, et al.How Telehealth Expansion Can Support Comprehensive Virtual Care. 

COVID-19 impact on oncology. Healthcare Research & Analytics. Accessed September 1, 2021. 

https://www.hraresearch.com/wp-content/uploads/2020/07/HRA_COVID-19_Infographic.pdf

Morency J. Coordination over silos: the new healthcare team. Hello Health. November 06, 2018. Accessed September 6, 2021. 

https://hellohealth.com/blog/coordination-over-silos-the-new-healthcare-team/

Goodman A. Online self-reporting of symptoms improves quality of life, extends survival. 

. June 25, 2017. Accessed September 9, 2021. 

https://ascopost.com/issues/june-25-2017/online-self-reporting-of-symptoms-improves-quality-of-life-extends-survival/

Articles

The use of these services in oncology is likely here to stay.

The Path to Optimizing Telehealth in a Post–COVID-19 World

Truism—a statement that is obviously true and says nothing new or interesting.

Those of us working in specialty pharmacy no doubt now accept the proposition that independent specialty pharmacies are facing unprecedented obstacles as an overused truism. But truism or not, the facts remain that access to therapies has become increasingly selective, pharmacy benefit managers (PBMs) continue to equate value with deep discounts, and the rapid rise of office-based dispensing is creating potential competitors out of our most loyal prescriber base.

How does an independent specialty pharmacy stay relevant and drive new opportunities in the face of these challenges? I contend that independent specialty pharmacies—those that can draw on grit, clinical expertise, and strategic vision&mdash;already have the core competencies needed to prove their unique value in this rapidly evolving health care market. Here’s how they can maximize the return on those competencies.

Independent specialty pharmacy must see health care cost through a different lens. We are witnessing the beginning of the end of the PBM carve-out model as the only means to manage pharmacy spend. The latest round of integrations between payers and PBMs signals a clear move to a carve-in model, in which payers will have the technology, resources, and data visibility needed to dissolve the mutually exclusive legacy silos that separate medical and pharmacy benefits and spending. This means PBMs will be even more interested in cutting costs to protect their bottom line.

But cost isn’t as straightforward as many think it is. When we focus too heavily on drug pricing as a unit of cost, we miss the hidden and very real costs of nonadherence and high incidences of avoidable adverse effects. Therefore, as PBMs work to keep costs down, they can inadvertently keep patients from getting the depth of care they need, which actually reduces cost.

Many of the high medical costs associated with poor adherence and reduced productivity are in fact avoidable. A recent study revealed that, astonishingly, $100 billion in potentially avoidable costs are driven by medication-related hospital admissions.1 In other words, between one-third and two-thirds of all hospital admissions happen because of patient nonadherence or adverse events. The same study estimated that the annual cost of medication nonadherence is likely $290 billion, more than 8% of yearly US health care spend.

Tragically understudied until recently is the hidden costs associated with reduced employee productivity. An October 2018 study calculated that year 1 productivity losses associated with a complex diagnosis, such as that of multiple myeloma, averaged nearly $16,000 per employee.

More than half of US employers fund all or some of their health plan’s medical spend. Imagine the benefit to employers that partner with health care providers that are uniquely able to help patients access, afford, and manage complex treatment. These providers would add value, drive lower overall medical costs, and improve patient outcomes by keeping patients on clinically beneficial treatment, out of the hospital, and productive, with a better quality of life.

When specialty pharmacies understand that costs encompass much more than drug prices, they can begin to take steps to assess the savings they help create through the adherence support they provide. They can then begin to ensure they can quantify that value for PBMs as well.

Independent specialty pharmacies must structure patient care to quantify their value in avoidable medical spend and optimized outcomes. To help PBMs understand the real cost of patient care, specialty pharmacies need to show how their patient management care programs save in total episodic spend. As an example, Biologics by McKesson recently secured approval from a PBM in the face of difficult administrative barriers to dispense a costly 5-fluorouracil toxicity antidote to a patient admitted to the intensive care unit of a rural Texas hospital. The medicine was couriered to the patient, who received the dose the following day and was discharged later that afternoon. Under the carve-out PBM model, the only cost evident to the PBM was the expensive antidote.

What was not clear was that the rural hospital was scheduled to transfer the patient to a large academic cancer center had Biologics not secured approval to deliver the therapy. In doing what it was uniquely trained to do, Biologics obviated an entire treatment episode.

To drive awareness and visibility into how they are bending the cost curve, specialty pharmacies must adopt an intervention outcomes—driven patient management strategy. They must know why they touch patients, what sentinel data they need to capture, and how to quantify the impact of their patient management on episodic cost.

Independent specialty pharmacy must articulate its unique value and position itself as a center of excellence. As long as we allow the health care industry to view specialty pharmacy as nothing more than a specialized distribution channel, access and margin pressures will increase. If specialty pharmacies understand and articulate effectively how the cost-effective care they provide improves how patients use the health care system and drives better treatment outcomes, they will be well on their way to becoming a center of excellence.

What, then, is a specialty pharmacy’s unique value beyond that? Pharmacies need to ask the right questions to help them develop their competencies, determine their value proposition, and ultimately gain the support of PBMs for the sake of patient care and cost savings.

		Would prescribers refer every patient to our pharmacy?

		How do I communicate with prescribers during the treatment episode, and do they see us as an extension of their clinical practice?

		Are we exhausting all efforts to help patients access, afford, and manage their treatment?

		How well do we know a patient’s ability to comply with treatment?

		Do we customize patient care plans according to the patient’s risk for noncompliance?

		How does our unique clinical expertise differentiate our pharmacy?

		Are we focused on a single therapeutic area, and are we especially skilled at supporting a vulnerable patient population?

		Do we have unique value in an individual treatment class or offer a unique distribution model?

When specialty pharmacies do their due diligence to understand where they are and where they need to be, they can increase their relevancy in the marketplace. Biologics took itself through this process and made an impact on its patient care and ability to help quantify its value to PBMs.

For example, in reviewing recent patient outcomes data for a particular therapy, we identified a significant number of patients who expressed moderate to severe distress. We were able to provide those patients with more than twice the frequency of clinical outreach than that of other patients. Therefore, even though patients reported a high rate of adverse effects, the entire group remained adherent at the prescribed dose, and only 1 patient reported an emergency department admission.

Specialty pharmacy is already providing significant value. The time has come to quantify it and use that knowledge as a strategic asset.

Independent specialty pharmacy must see health care cost through a different lens.