Health-System Specialty Pharmacy Built to Evolve

Growing demand for specialty care, shifting prescriber habits, and new reimbursement models have forced stakeholders to adjust practices to optimize patient outcomes.

A convergence of factors in specialty patient care have spurred innovation and creativity from providers, payers, and pharmaceutical companies to adapt to an evolving landscape. The growing demand for specialty care, shifting prescriber habits, and new reimbursement models have all forced stakeholders to reevaluate their specialty care and adjust their practices to optimize patient outcomes.

M Health Fairview, Sentara Healthcare, Novant Health and MedStar Health have each employed a coordinated strategy to meet the increasingly complex demands of specialty patient care. Those health systems recently participated in a webinar on that subject hosted by Shields Health Solutions that I moderated. Below, I share some of their key insights from our discussion:

The specialty pharmacy landscape in 2021

First and foremost, among changes to the landscape, the market for specialty drugs has grown from $162 billion in 2015 to $248 billion in 2020. That growth curve will continue on an upward trend, as about 60% of new molecular entities awaiting FDA approval through 2021 are classified as specialty pharmaceuticals.

There has also been a shift in prescriber behavior, as more than half of all physicians are employed by medical groups or health systems and integrated delivery networks (IDNs) account for a higher percentage of scripts written. As value-based reimbursement models become more widely adopted and health systems assume more risk for patient outcomes, prescribers have more incentive than ever to encourage adherence and monitor their patients more closely.

Health-system specialty pharmacies have several inherent advantages in meeting the ongoing challenges in specialty patient care and are well-equipped to adapt to new demands that may arise.

The power of data and reporting

Integrated health systems have more data at their disposal today than ever before, which have aided in developing much more sophisticated measuring tools. Paper-based patient surveys on a clipboard with a set of generic questions have been replaced by software that generates detailed service and experience metrics. It can show patient satisfaction measurements and benchmark those data against similar pharmacies, providing a crucial litmus test that helps the health-system pharmacies stay competitive in the market and provide the best possible patient experience.

Today’s technology capabilities have also been instrumental in improving outcomes and ultimately controlling the cost of care. Therapy management systems have come a long way in their development over the past decade, helping to improve data analytic capabilities, measure adherence, and measure understanding of quality-of-life metrics and lab values.

Even with the tremendous advances in data and reporting, there remains room for growth in benchmarking and defining what constitutes success—especially related to controlling costs for the patient. Lessons learned from the data can help mitigate unnecessary spending on trips to the emergency department or a clinic visit, but there’s still much to learn on individual patient spending and strategies for controlling it.

Elevating patient care and management

Many of the roadblocks that arise in treating complex patients stem from access issues—access to the right payer network or to the right limited distribution drug to prescribe the patient. But health-system specialty pharmacies in a network with the size, scope, and scale of the Shields network have developed extensive connections with those payers and drug manufacturers that separate them from other types of pharmacies.

When a health system-based specialty pharmacy has the advantage of continuity of care, the burden of responsibility that comes with value-based reimbursement is much more manageable. Keeping a patient within the health system means the care team can oversee every aspect of the patient’s care. Those critical relationships with payers and manufacturers are an important way to establish continuity and ensure the patient is getting the appropriate treatment.

What’s on the horizon

The future of specialty care will rely even more heavily on digital tools that enhance the patient experience. The pandemic forced a shift to a more digital-centric model of care with the adoption of telehealth and providers have found instances in which telehealth may even be preferable to in-person care.

Pharmacies that can leverage digital technologies such as telehealth for patient management, monitoring, and drug adherence will stand to make tremendous strides in their outcomes. Enhanced digital tools will also bring the ability to share clinical data insights across health systems more freely. The value of sharing insights across providers cannot be overstated when discussing the rare and orphan diseases that have limited clinical data for reference.

For health system-based specialty pharmacy in particular, challenges are coming in the form of payer-pharmacy benefit manager-specialty pharmacy conglomerates that could threaten the relationships health systems have with payer networks. Payer relationships outside of the health system have led to some troubling trends, such as the practice of payer-mandated white bagging, in which prescriptions for physician-administered drugs are filled at a third-party pharmacy.

This practice is jeopardizing patient safety and can potentially compromise the quality of patient care. ASHP issued an official opposition to the practice in March 2021.

By continuing to demonstrate value through exceptional, high-touch patient care and leveraging its vast array of resources, the health system-based specialty pharmacy is well positioned to answer the challenges of today while continuing to evolve with the inevitable changes of complex patient care.

About the Author

Diane Wolfe, RPh, is the Vice President of Network Strategy at Shields Health Solutions.

Shields Health Solutions is the premier specialty pharmacy accelerator health system leaders trust to elevate clinical, operational and financial performance.