The high number of specialty drugs emerging into the marketplace has increased competition among independent pharmacies and chain pharmacies. As the health care industry moves towards value-based reimbursement, health plans, pharmacy benefit managers (PBMs), physicians, and hospitals are looking to partner with pharmacies that have proven the ability to deliver high-value care at a low cost, according a new white paper from URAC.
 
To engage in competition, specialty pharmacies must create a sustainable way to improve processes, while also gathering and sharing data that highlights their ability to improve adherence and outcomes.
 
Continuously measuring and improving performance adds another piece to the “Five Rights” of medication distribution (the right patient, the right drug, the right dose, the right route, and the right time): the “Sixth Right,” the right result, according to the study.
 
“Pharmacists and pharmacies have evolved from playing supporting roles to being vital leaders in managing patient care and improving outcomes,” said Kylanne Green, URAC’s president and CEO.
 
It is no secret that the specialty pharmacy industry has boomed in the past 5 years, partially influenced by a plateau of generic drug use, increased utilization of specialty drugs, and a vast developmental pipeline. As more drugs are approved, the amount of PBMs, retail chains, health plans, wholesalers, physicians, hospital systems, and independent specialty pharmacies are all competing to sell the same drugs, according to the report.
 
Specialty pharmacies are now facing market pressure to move towards value-based care. Since the complicated treatment regimens are costly and require management services, payers require PBMs to manage utilization and reimbursement. PBMs trust accredited specialty pharmacies to focus on adherence and patient outcomes for optimal cost control.
 
“The need for managing patient care throughout the course of therapy will never be greater,” Green said. “Pharmacists and pharmacies that begin to adopt fundamental elements of the new value economy, those who position themselves as an essential part of the care team, will succeed.”
 
Recently, value-based reimbursement under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was revised to change how providers are paid for patient outcomes, which places an emphasis on improving overall care, according to the report. This has significant implications for specialty pharmacy competition.
 
“Physicians are care team leaders under MACRA,” Green said. “If physicians benefit financially by partnering with top-performing pharmacies who help them improve quality, they will seek them out.”
 
To ensure that they are viewed as a valuable member of the care team, pharmacists must have a vast understanding of complex disease states, which includes making therapeutic recommendations and collaborating with other providers to demonstrate their value, according to the report.
 
“Pharmacists and pharmacies who can demonstrate their ability to manage medication and thus demonstrate their value will be recruited by accountable care organizations, clinically integrated networks and patient-centered medical homes,” Green said. “Pharmacists will no longer play supporting roles. They will be vital leads.”
 
Perhaps the most important component of value-based care is performance measurement, the authors wrote. To be competitive in today’s market, pharmacies must tie their interventions to positive patient outcomes, according to the study.
 
Adherence measures have become a hallmark of a specialty pharmacy’s value, as this can mitigate hospitalization and other avoidable costs. While adherence to complex treatments can present a unique challenge for each patient, specialty pharmacies have implemented effective strategies, including integrated refill reminds and care management programs.
 
“That’s what makes specialty pharmacies so vital,” Green said. “They’re not just managing the drug, they’re managing the whole process. The pharmacist connects with the patient and the pharmacy collects the resulting data, analyzes it and makes it actionable so that it can inform future efforts.”
 
Adding the “Sixth Right” to the mix highlights the importance of patient outcomes and value-based care, according to the report. Without the right result, the costly medication can be deemed unnecessary, resulting in waste. This principle is central to URAC’s Specialty Pharmacy Accreditation program.
 
“The high-price of specialty pharmaceuticals and the potential impact on patient safety requires specialty pharmacies to have specific competencies for tracking how patients respond to a drug therapy and ensuring patients have the appropriate outcome,” Green said.
 
Achieving the right result is crucial for promoting optimal outcomes, preventing hospitalization, and reducing costs, URAC reported. Specialty drugs require substantial coordination between various health care providers, with pharmacists providing crucial education and monitoring throughout therapy. The shift away from fee-for-service reimbursement reinforces the importance of specialty pharmacist involvement in an episode of care.
 
Additionally, since many PBMs and health plans primarily partner with pharmacies that have a proven record of beneficial outcomes, accreditation has become a necessity. Accreditation allows stakeholders to see that a certain pharmacy consistently meets high standards set by the program.
 
Even as therapeutic options for multiple sclerosis, cancer, and rheumatoid arthritis continue to dominate the market, orphan drugs may also account for a significant share of the market in the future, according to the study.
 
Orphan drugs coming to the market provides an additional opportunity for specialty pharmacies to set themselves apart from the competition through developing and sustaining clinical, logistical, and operational practices for small patient populations with complex diseases.
 
This expansive growth in specialty will continue to attract more players, which makes staying competitive especially important. Payers will likely continue the trend of seeking only accredited pharmacies that have demonstrated their value. Pharmacies that are accredited and patient-centered will be the best positioned to gain business, the report concluded.
 
“Pharmacy practice is undergoing a transformation: from an operational focus to providing more value-based services. This is a positive trend for patients as well as the industry,” says Heather Bonome, URAC’s director of pharmacy. “URAC understands what’s necessary to make this transition, and our accreditation program facilitates the process.”