Although the prevalence of health system-based specialty pharmacies has grown steadily over the past decade, 2020 will mark a critical year. Payers, providers, and health systems themselves are increasingly recognizing the important role integrated delivery solutions play in value-based care initiatives.

The growth in health system-based specialty pharmacies has been buoyed by the double-digit annual rates of growth in specialty drug costs, coupled with an increasing number of health systems bearing the liability for the high-risk patient populations they serve.

The integrated structure of health system-based specialty pharmacies positions them well for delivering on quality patient care, as well as partnerships with drug manufacturers and payers seeking new opportunities to work with health systems.

Health Systems Lean Toward Specialty Pharmacy and Pharmaceutical Strategy

The convergence of growth in the specialty drug market along with the consolidation of health systems has created both challenges and opportunities in the marketplace. On one hand, a battleground has emerged between providers and pharmacy benefit managers (PBMs), who are interested in growing their specialty pharmacy revenues.

On the other hand, as a result of considerable consolidation, many health systems now possess the critical mass to act as a PBM for their own employees and the broader communities or regions their health plans serve. The ability to move the PBM within the health system, or within a group of health systems, suggests impending moves from health systems to realign or internalize pharmacy benefit management, which will create natural alignment with stakeholders and an ease of use that is lacking in the current PBM landscape.

Additionally, the consolidation of health systems provides them with the means to extend their reach into areas of specialty pharmacy that encourage drug adherence and continuity of care while controlling total cost of care. Home infusion for specialty patients is an example because it is not only convenient for the patient, it frees up hospital beds for more critical patients who require infusion services and can cost significantly less than traditional hospital-based infusion. 

Drug Manufacturers Increasingly Recognize the Importance of Integrated Delivery Networks

As health system-based specialty pharmacies grow and gain accreditations, pharmaceutical companies and drug manufacturers alike continue to realize the rich data sources these health system-based specialty pharmacies represent. Collaborations between health systems across the United States, such as the Excelera Network, represent an even bigger data opportunity, as they offer a single source for the highly sophisticated data sets drug manufacturers require.

Nationwide health system networks and data aggregator partners such as these are beneficial for 2 main reasons. First, they provide single-source access to myriad health systems, which can simplify contracting and data access, reducing bandwidth and personnel required to support an integrated-delivery network strategy. Second, as drug manufacturers seek to gain a deeper understanding of the patient journey within the health system, they now require health system-based specialty pharmacies to provide the same level of sophisticated data for limited distribution drugs (LDDs) as they require from national specialty pharmacy partners.

By working with a network partner or data aggregator, data are provided in a standardized format, which means the data are often even more accessible and digestible to drug manufacturers. That allows deeper insights into real-word use of specialty products and a clearer understanding of the patient journey.

Partnerships Drive Value-based Results

As price tags for many specialty medications rise for complex patients in small populations, value-based contracting becomes increasingly necessary. However, as the data requirements are still difficult to define, collaboration among all players—drug manufacturers, data aggregators, payers, and patients—will be critical. Drug manufacturers are in the best position to determine which product data are most relevant, whereas health systems have more knowledge into which insights will elucidate the patient journey.

Reaching a consensus will help the industry determine the right questions to ask and the best real-world data to mine to gain the insights needed to reduce total cost of care and improve patient outcomes. Additionally, as we gather data from an increasing number of health systems, the analysis and synthesis of these data are an important factor to success.

A New Decade

While the prevalence of the health system-based specialty pharmacy has grown steadily in the previous decade, we have reached an inflection point in which the pieces are now in place to deliver more impressive results, particularly in meeting broad value-based care goals. In the coming year, we expect to see health systems better leveraging their collective scale, both with drug manufacturers and benefit managers, creating a more competitive margin equation.

Additionally, health systems will likely continue to extend their patient reach to include areas such as home infusion and preferred specialty pharmacy network participation. This greater degree of collaboration will allow for more comprehensive clinical data sets that would otherwise have been unavailable, while providing consumers with timelier therapy management at the point of care.

Overall, if the collaborative spirit we have seen in the industry in recent years continues, we will be on a positive trajectory to better control costs and make health care affordable for our most complex patients.