Differentiating Specialty Pharmacies From Hub Services
With the growth of specialty medications and the high-touch care that is needed to ensure optimal outcomes, a niche market focused on providing ancillary services for these drugs has grown in popularity.
What is a Hub?
Prior to engaging in the Master of Science in Pharmacy Business Administration program at the University of Pittsburgh, I had no clue what a hub service was, let alone the fact that they even existed. However, hub services have been around for quite some time.
Hub services began operating similarly to a call center to help manufacturers in offering financial assistance that support access to their medications. With the growth of specialty medications, particularly orphan drugs, and the high-touch care that is needed for many of these drugs in order to ensure appropriate administration, use, and clinical efficacy, a niche market focused on providing ancillary services has grown in popularity.
Having a single point-of-contact enables manufacturers to ensure efficient medication distribution. Companies such as the LASH group, Sonexus, and EnvoyHealth are all examples of companies that provide hub services for various specialty medications. Hubs are typically either standalone entities or they partner with specialty pharmacies.
These operations serve as go-betweens for manufacturers and specialty pharmacies to assist patients in obtaining care and helping manufacturers provide a consistent experience to patients with respect to their medications. Hubs are able to perform a number of key functions, including reimbursement services, distribution services, adherence or clinical monitoring, and outcomes reporting.
Manufacturers ultimately decide whether to use a hub as part of a marketing strategy and, if so, which components of the service model will be included or managed by the hub.
Let’s explore each of these functions in more detail and why a specialty manufacturer may utilize a hub service versus relying on a specialty pharmacy to perform some of these key functions.
Reimbursement services encompass a number of functions, including channel referrals, benefits investigation and verification, and payer policy investigation. Channel referrals ensure that all prescriptions for a particular medication are funneled through the hub rather than a prescription given directly to the patient or faxed directly to the specialty pharmacy.
In this instance, a hub acts as an aggregator of specialty pharmacies and can ensure a consistent experience and approach to filling a medication. This process allows physicians to communicate with an individual contact to have a medication filled versus having to remember whether or not a particular specialty pharmacy has access to it.
In addition to acting as a central touchpoint for all stakeholders involved in the specialty process, hubs can provide comprehensive benefits investigation and verification services for patients. Benefits investigation and verification can include anything from coverage determination to working through various payer policy requirements.
By being familiar with a particular medication’s billing codes and overall adjudication process, the time it takes to process the claim may be cut down, leading to a faster time-to-fill. Additionally, benefits verification can provide patients with options regarding financial assistance, if needed. Hubs can also report back to the manufacturers on various data points, such as the most common reasons a medication may be rejecting or the most common barriers to care, just to name a few examples.
From a payer policy perspective, because many specialty pharmaceuticals are high cost and typically require additional monitoring to ensure efficacy, many payers require prior authorization. Hubs can therefore help to expedite prior authorizations or other utilization management programs that may be necessary by assisting with the documentation needed to process the request or by obtaining additional information from the provider in order to complete the process.
Another service that some hubs provide while prior authorizations are being reviewed is the ability to dispense a bridge supply of medication in order to start a patient on therapy as soon as possible.
In addition to reimbursement services, hubs are able to offer a number of distribution services as well. These services may include acting as an administrator of the manufacturer’s third-party logistics or an administrator of patient assistance programs. They can also serve as a coordinator for clinical trials, as well as a wholesaler to health systems.
Adherence and Clinical Monitoring
Besides managing more administrative processes, hubs can also assist with more clinical aspects of medication management. For example, hub services can support a manufacturer’s efforts to ensure medication adherence in order to optimize outcomes and avoid medical complications.
Additionally, hubs can provide clinical monitoring services for the medications they support, such as collecting lab values, blood counts, or even confirmation of additional tests that may be needed to continue therapy. They can also assist with locating nursing services to provide home-based infusions, adverse effect management, and overall condition management to optimize clinical outcomes for patients, suggesting interventions when necessary.
Hubs can also assist manufacturers with any risk evaluation mitigation strategies (REMS) that are required by the FDA for their product. Finally, hubs are not only able to provide many of these clinical services, but also report results to the manufacturer that assist with post-marketing efforts and help them determine whether to provide additional interventions that assist patients with therapy.
Advantages of a Hub
Based on the above service descriptions, we can see there are many reasons why a manufacturer may want to utilize a hub and ultimately provide dedicated and customized services in support of their medication. These services can focus on some or all of the areas discussed, including reimbursement, distribution, and clinical monitoring.
Regardless of the services selected, which are chosen based on what is needed for a particular medication, a hub is ultimately able to provide a consistent approach to fulfillment and patient experience. They can potentially provide faster initiation of therapy through the availability of bridge supplies, the expedition of payer policies—such as prior authorizations—and by having the most up-to-date knowledge of which specialty pharmacies are able to dispense a particular medication.
Hubs may also be able to foster better relationships between manufacturers and prescribing physicians simply because they are the sole point-of-contact for the medication. Additionally, hubs can enhance access to patient assistance programs and allow for the collection of meaningful patient data that the manufacturer can use for post-marketing purposes or to continue to enhance the program support available to its patients.
Other ancillary services, such as nursing support, transportation services, and clinical monitoring, can all lead to better outcomes for patients. All in all, hubs are able to help demonstrate the value of a medication by providing direct support for the product and ensuring positive health outcomes, which continues to be a significant measurement of success—especially as we continue to move towards value-based care.
Although there are a number of advantages to having a hub in place, it may beg the question of why a hub is necessary if many specialty pharmacies are equipped with the ability to perform many of these same functions already, such as benefits verification, clinical monitoring, and reporting. Some argue that a hub’s revenue is based solely on providing services for a single product, while specialty pharmacies are focused on appropriately dispensing and supporting multiple products.
Therefore, hubs may provide better, more specific support services; however, many of the specialty pharmacies that I have been privy to have teams that are specifically dedicated to therapeutic classes and, therefore, a similar level of support would likely be provided by both the specialty pharmacy as the hub. Additionally, why is it that some specialty products that have utilized a hub historically do not use it when the medication launches generically?
Take Xenazine, for example, which must be filled through a hub whereas the generic, tetrabenazine, is simply provided to specialty pharmacies via physician referrals. Although I certainly see the advantages of having a hub in place and am in favor of providing services that improve patient experiences and optimize outcomes, it would be interesting to see statistics related to endpoints such as time to fill, prior authorization approval, abandonment rate, adherence measures, and REMS completion rates between specialty pharmacies and hubs that have access to these medications.
In my opinion, it may make more sense to have a hub in place for specialty medications that are not part of a limited distribution network. Reason being, with a limited distribution medication, you already have a smaller network of pharmacies that have access to the medication and can deliver a similar patient experience and approach to filling the medication across all pharmacies.
With medication that is available in an open network and can be filled through any specialty pharmacy channel, it may be harder to control the patient experience and process through which the medication is filled. One of the potential issues with not having a hub in place for a limited distributed medication is that a physician may not always know where to fill the medication for their patient, as access can change based on payer and manufacturer contracts.
However, I imagine physicians who are specialists in these areas receive information regarding these updates quite frequently. Another concern may be the level of clinical monitoring offered to a patient through the specialty pharmacy versus the hub, but this could be a negotiating factor when selecting the specialty pharmacies that will be part of the limited network.
In summary, specialty pharmaceuticals are certainly an area of focus, not only from a research and development perspective, but also from a payer perspective. They are the wave of the future and offer treatment for conditions we never anticipated.
Finding the right mix of specialty hubs and pharmacies to deliver positive health outcomes and manage costs will be key as we continue to see more of these medications launched.
About the Author
Lauren Meyer earned her Doctor of Pharmacy degree from the Duquesne University School of Pharmacy and is currently enrolled in the Master of Science in Pharmacy Business Administration (MSPBA) program at the University of Pittsburgh, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines. She has spent the past several years working as a clinical advisor assisting employers with their pharmacy benefit management strategy. Prior to this experience, she completed a PGY-1 managed care residency.