Lessons from Launching a Health System Specialty Pharmacy
Question: As a health system covering lives in the mixed rural/small city region of western Michigan and northern Indiana, what were some of your considerations and concerns when you first thought about starting a specialty pharmacy?
Shaun W. Phillips, PharmD, MBA, vice president for Clinical and Pharmacy Services at Bronson Healthcare: It all really started with our patients. Across our entire health system, we saw that we had providers covering the most common specialty disease states, including neurologists, oncologists, rheumatologists, and gastroenterologists for both adult and pediatric patients.
Before starting our own specialty pharmacy, our patients would be prescribed specialty medications and our clinic staff worked overtime to complete prior authorizations and copay assistance for patients, or determine where the drugs could even be filled. The provider offices had scarce resources to do all of that additional work on top of their important clinical care. While I wouldn’t say patient care suffered, patient care was definitely fractured between their Bronson providers and outsourced specialty pharmacy services. That fractured system made care more difficult for patients and providers alike. Owning our specialty pharmacy would allow us to integrate the care provided by the physician with the care provided by the specialty pharmacy for patients while greatly reducing administrative work for our care teams across Bronson Healthcare Group. We knew that there was a better way of doing this and we knew that if we did it ourselves here at Bronson, we could offer a better patient-centered experience, one that provided services faster and closer to home.
Q: What made you decide to partner with a specialty pharmacy integrator to build your own hospital specialty pharmacy?
SP: We considered a range of options from on-site consultants, to outsourced staff, to a mosaic of associations that provided access to limited distribution drugs. A big consideration with each option was speed to market. In the end we knew it was best if we fully owned the pharmacy but we needed new expertise and capabilities faster than we could learn them on our own.
So we went with a specialty pharmacy integrator, Shields Health Solutions, which gave us immediate expertise in payer access and LDD access along with in-clinic staff and all of the back-end support capabilities we needed to get up and running in a few months instead of years. Starting the specialty program quickly was essential because we felt like the “specialty window,” if you will, was closing, and in a couple of years it would be completely shut and we did not want Bronson to be locked out.
If we had done this on our own, we would still have been successful, but it would have taken us 18-24 months to provide service instead of the 6 months we experienced with Shields. Also, the number of resources that Bronson would have had to employ on our own would have been a heavy lift. By leveraging Shields’ model and their teams of experts, Bronson has not added additional in-house resources. We use the Shields’ clinical pharmacy team for patient follow-up and care continuity, their accreditation experts to speed up our time to dual accreditation, as well as many other resources.
A significant factor in our decision to partner with Shields was to see their model in action. Our Bronson team visited the UMass Memorial specialty pharmacy, which Shields helped create. When we saw the specialty pharmacy and patient Liaison staff working in sync with the clinical teams, we knew they had the best care model for our program. I thought the care model was something that providers could really identify with and get behind quickly.
Now that we are fully operational at Bronson those assumptions have proven true. When patients see the services we are able to provide right there in each clinic they are far more likely to fill with us. And initial data is showing better adherence and outcomes among other measures.
From a staff perspective, having the pharmacy liaisons in-clinic is removing administrative burdens from the clinical team and from providers. It is really saving a lot of headaches and making our employees’ job satisfaction exponentially better.
Q: Can you take me through what the life of a patient was like in a previous fragmented care system before you started your in-house specialty pharmacy at Bronson?
Troy A. Shirley, PharmD, MBA, system director of Pharmacy at Bronson Healthcare: For a patient in need of a specialty medication, the provider wrote the prescription and then signed the prior authorization form. From that point, the provider was working under the assumption that the patient had received and was taking the medication. In the legacy, fragmented specialty pharmacy model, the provider received no confirmation that the medication was being taken or if the patient was having any problems with their medicine, or if they were experiencing any roadblocks to being adherent.
From a patient perspective, these medications were, and still are expensive. Without a mechanism in the pharmacy or clinic to facilitate financial assistance, a portion of patients could not get their specialty medication filled because they could not afford the high copay or out of pocket expense. When the patient came back to visit their provider in 6 months, and the provider was under the impression that the patient had been taking the therapy, the provider struggled to understand why the response was not what was expected. It’s that lack of visibility for providers that reveals the depth of the fragmented care issue we were trying to solve.
SP: The legacy specialty pharmacy model was definitely disjointed from a technology perspective too. At Bronson, we have a “one patient, one record” mentality across our [electronic health record] computer systems. We are able to link up emergency department visits, urgent care visits, primary care visits, specialty visits, and hospitalizations all in one record. We want to be able to do that with the ambulatory experience too—specialty medication being one of those. We knew that unless we were able to start wrapping our arms around specialty medications and providing better visibility to the provider, it would continue to be a vital piece missing from every patient’s medical record. The fragmentation really affects patients’ treatment too because inevitably there are delays in initiating therapy due to the back and forth information needs between the provider, the patient, the pharmacy, and the pharmacy benefit managers. We’ve heard this from our providers, from the specialty clinics, and even from patients themselves.
Q: What has been some of the feedback so far from patients and providers now that Bronson has its own specialty pharmacy?
SP: Let me first start with providers. They really appreciate having the in-clinic pharmacy liaison available and love having this option to assist their patients navigate the specialty pharmacy world. Our oncologists recently told us that they, “want to use these resources more and more,” and ask us how they can get more of this type of service.
Patients love it as well. We have brought in more than $2.1 million dollars of financial assistance for our patients through the work of the specialty pharmacy liaisons. Patients really appreciate when our liaisons relieve that incredible financial burden from them. Across all of Shields’ health-system partners, patients total medication out-of-pocket expense averages under $10, and they are showing us how we can get there too.
As you can imagine, the executive team has also not only been impressed with the quality of care provided by the new specialty pharmacy, but also with the financial impact to Bronson. Our program began providing a positive contribution margin starting in month four of operations. You do not see that with every new service you bring up in a health system.
TS: As part of our learning curve, we knew we would not be able to fill every specialty medication right away due to contract lockouts or payer/pharmacy benefit manager issues. But for those specialty medications that we could access right away, our patients definitely saw immediate value. Our in-clinic pharmacy liaisons prioritize the prior authorizations and follow them through completion. It has resulted in a much shorter time to therapy initiation. From that regard, the patients have been very pleased.
Q: How are you measuring successful patient outcomes?
TS: The industry standard for specialty medication time for initiation is around 14 to 20 business days. Our program has been able to have patients start therapy in about seven business days. This is driven largely by an average prior authorization turn-around time of just two days. This is a drastic reduction from the time a patient sees her or his doctor to actually having the medication in hand. To me, that’s a significant quality of life issue. With rheumatoid arthritis, for example, patients start to realize the benefits from some of the biologic drugs within a week or two, and by accelerating that time-to-therapy a patient can start to experience feeling better more quickly. This is a significant quality of life improvement.
Q: What are some of the biggest challenges you have faced?
Holly Wagner: Beginning with the barriers, I think that specialty pharmacy is a very niche, complex area. Even as a pharmacist that has worked for the past 10 to 15 years in retail pharmacy, specialty pharmacy is still hard to figure out. Having a partner that understands the payer landscape, the limited distribution drug networks, the accreditation preparation and the clinical pharmacy programs right out of the gate helped us tackle our biggest challenges.
SP: The complexity issue carried through to our executive team too. We spent a lot of time educating them on the care improvement and revenue aspects of specialty pharmacy. For that team to consider specialty pharmacy as a growth area we all had to get on the same page. So, we did a lot of education about why we wanted to do this initiative now, why we wanted to get into this space at all, and most important, why this was going to be better for our patients.
Q: If you were talking to your peers at different health systems what advice that you would give them?
TS: Specialty pharmacy is an opportunity that anybody can get into as long as there is the organizational commitment. There are financial implications, and a significant commitment of time, effort and energy to implement. It has to align strategically with what your health system is ultimately trying to accomplish. As long as that organizational commitment is there, this is a doable endeavor. We are not out here trying to compete necessarily with the national players in the market, because we just want to focus on our own Bronson patients and provide them with the full continuum of care from start to finish. This is a piece that we know we can do better. We’ve demonstrated that we do a better job for patients, and providers, by keeping the specialty pharmacy within the four walls of Bronson as opposed to outsourcing to national chains.
Holly Wagner, RPh, system manager, Pharmacy Outreach at Bronson Healthcare: I would tell my peers that this project will just require patience and the willingness to learn. I welcomed Shields’ knowledge and their willingness to teach. I’ve worked with great people across their company. You have to be very patient and just know that there is a lot of work ahead of you, but it will ultimately provide the best care possible to your patients.
We felt that if we owned and operated our own specialty pharmacy we could improve that quality of care and reduce fragmentation for all stakeholders. We also knew that this would be a vital revenue source that we have traditionally given to profit-driven pharmacies. We are always looking for new ways to better serve our patients and hopefully break even while doing it, and we thought specialty pharmacy was one area of untapped revenue for Bronson that would allow us to keep to our mission of providing the best possible care, especially during a time when payers are transitioning from fee-for-service to outcome-driven reimbursement.