Building the Case for Integrated Care With Specialty Pharmacy in Health Systems
Specialty pharmacies are the primary provider of oncology-related medication therapy.
Cancer is an indiscriminate, tenacious foe, making health care treatment more costly and complex. An 18% increase in new diagnoses from 2002 to 2017 has fueled a market determined to eradicate this disease.1 This has led to more than 40 oncology-related drug applications filed in 2020.2 Specialty pharmacies have become the primary providers of oncology-related medication therapy. Health system-owned or -integrated delivery networks are increasing.
Health system specialty pharmacies have grown from 7.8% in 2015 to 26.4% in 2019.3 Their value proposition, in many respects, resembles that of a typical specialty pharmacy. However, characteristics unique to health system specialty pharmacies are essential for optimal patient care.
Most specialty pharmacies include the core components of financial, operational, and clinical services. Financial services include benefits investigation, insurance authorization, copayment assistance, and ensuring patients understand out-of-pocket costs before starting therapy.
Operational services include refill calls, cold-chain shipping, and a distribution model that provides quality and consistency in medication preparation and delivery. Clinical services include therapy evaluation, medication reconciliation, adverse effect (AE) management, objective and subjective reassessment, and constant on-call assistance.
All components are expected to provide the highest level of service. Health system specialty pharmacies use their surrounding networks to integrate and expand these core components, and that is how their value differs from that of other specialty pharmacy models.
This value is recognized through organizational alignment, with team members sharing the mission, vision, and goals. This means the specialty pharmacy is focused internally, and the stakeholders are the patients, providers, and brand of the health system.
With this alignment comes one of the greatest benefits: the integrated medical record. Having timely access to the right information, and a secure, reliable method of communicating, is essential to the value of health system specialty pharmacies.
Treating and caring for patients with cancer requires a well-integrated care team. This model allows such continuity of care. It also allows accountability to patients, providers, and payers. However, simply having access to a health system network does not make a specialty pharmacy successful. A strategy must bring the key pieces together.
That strategy must be tailored to specific disease states, and align with the health system’s goals. In an oncology service line, there should be emphasis on financial and clinical components of the specialty pharmacy. Financial barriers will dictate a patient’s therapy options, and clinical knowledge is key to an optimal treatment regimen. A crucial component is positioning the specialty pharmacy to have access to limited distribution drugs, many of which are specific to oncology.
A health system pharmacy with an integrated care team and medical records department is well posi- tioned to handle the financial and clinical components. Even so, these systems should consider seeking assistance in the pursuit of limited distribution drugs.
Network administrators, such as Acentrus Specialty of Irving, Texas, support the success of health systems and hospitals as the ideal providers of integrated specialty pharmacy care. They have assisted many health system pharmacies in obtaining access to limited distribution medications for their patient populations.4 Overall, executing this strategy will provide seamless care to patients within the oncology service line.
When all the components come together, the patient journey will showcase efficiency and quality. For example, a 45-year-old patient with a medical history of chronic lymphocytic leukemia has decided to begin ibrutinib (Imbruvica; Pharmacyclics and Janssen) therapy based on results of a recent bone marrow biopsy.
The physician meets with the patient, reviews the treatment plan, and places an order. The electronic prescription immediately reaches a board-certified oncology pharmacist’s work queue. This clinic-based pharmacist reviews the medication order, dose, frequency, and cycle length. Next, the pharmacist reviews any pertinent drug-drug interactions that may be present, recommends a monthly complete blood count to monitor for cytopenia, and supportive medication therapy treatment that will be provided concurrently with treatment. Once approved, the pharmacist releases the order to the health system specialty pharmacy, which begins a financial evaluation.
A benefit investigation reveals the need for a prior authorization. A certified pharmacy technician within the specialty pharmacy pursues that authorization, obtaining all necessary information from the shared medical record. The prior authorization is approved, and documented within the medical record for all care team members to see. Likewise, the patient has received information on the option of using a copay card and has authorized the pharmacy to assist in obtaining this benefit.
Next, the certified specialty pharmacist within the specialty pharmacy reviews the order and care team members’ previous notes. The pharmacist contacts the patient to provide education on the medication, therapy plan, adverse effects, supportive medications, and to answer questions. Afterward, the pharmacist documents the counseling session within the integrated medical record and confirms with the care team that the patient is ready to begin therapy.
The pharmacist asks for the supportive medications to be sent to the patient’s preferred retail pharmacy for nonspecialty products, and the patient is set to begin therapy. This start date is communicated to all team members, and a follow-up assessment is scheduled by the specialty pharmacist 14 to 21 days out to assess how the patient is tolerating treatment.
All of this is accomplished in less than 36 hours, during which not a single piece of paper is faxed. The clinic staff remains focused on the patient, not on prior authorizations, and all team members retain visibility into the status of the patient’s medication journey.
These factors remain true throughout the patient’s therapy, while the patient stays within the health system specialty pharmacy. This leads to the care team’s awareness of medication adherence, AE management, new medications onboarded, and potential drug-to-drug interactions, as well as tracking a patient’s progress toward a given outcome. This is the direct result of a team with a shared mission, vision, and goals operating within a shared medical platform to benefit a patient fighting cancer.
This is often not how these scenarios play out. Rather, a patient’s insurance will require a specific pharmacy to fill a prescription. This pharmacy will not be integrated with the provider clinic, may not provide insurance assistance, will mail the medication to the patient without confirming supportive medications or specific start dates, and will not report any pertinent information to the provider.
In this case, when a patient calls the provider regarding the status of the medication, the clinic will have no visibility into where it is in the fulfillment process. The lack of integration leads to inefficiency, lack of transparency, and fragmentation in care. That is the status quo of today. The key question becomes whether the health system specialty pharmacy model is effective enough to change that status quo.
A recent specialty pharmacy insights report sheds light on the fact that many health plans do not see the immediate value of this model. One payer said they see this as a commodity space, stating, “It doesn’t matter to me who’s providing this commodity service.” Another suggested there is no difference between a health system specialty pharmacy and others in the marketplace, stating, “A pharmacy is a pharmacy is a pharmacy.” One payer identified a concern regarding the health system model, stating, “These are all just line extensions. It’s not their primary business, so it’s just not their focus.”5
There is work to be done to show the value of the health system specialty pharmacy model, and it is up to health systems to have a strategy in place to objectively and subjectively show this value to all parties. That is the mission many health system specialty pharmacy leaders are beginning now.
The marketplace for oncology therapy will continue to evolve, as will expectations for specialty pharmacies. Health system pharmacies provide an optimal patient care journey through alignment with an integrated health system. However, translating that into objective value is a critical step.
BRYAN SCHUESSLER, PHARMD, MS, is the director of home infusion and specialty pharmacy at Saint Luke’s Health System in Kansas City, Missouri. His interests include ambulatory pharmacy design, and leadership development.
- U.S. Cancer Statistics Data Visualizations Tool, based on 2019 submission data (1999-2017). Centers for Disease Control and Prevention. June 2020. Accessed November 23, 2020. www.cdc.gov/cancer/dataviz
- OptumRx. OptumRx Drug Pipeline Insights Report. 2020. Accessed November 23, 2020. https://www.optum.com/content/dam/optum3/optum/en/resources/PDFs/OptumRx_Q1_2020%20PipelineInsightsReport.pdf
- Pedersen CA, Schneider PJ, Ganio MC, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2019. Am J Health Syst Pharm. 2020;77(13):1026-1050. doi:10.1093/ajhp/zxaa104
- About us. Acentrus Specialty. Accessed September 20, 2020. https://www. acentrusrx.com/about-us
- Specialty pharmacy insights: aligning health systems and health plans for better patient-centered care. TrellisRx. 2020. Accessed November 23, 2020. https://www. trellisrx.com/resources/specialty-pharmacy-research/