Experts discuss expectations for home infusion and specialty pharmacy in 2018 at the MHA Business Summit.
Several new and ongoing trends are expected to be of significant importance in the home infusion and specialty pharmacy space, according to a panel discussion held on March 7, 2018, during the 2018 Fifteenth Annual MHA Business Summit in Las Vegas.
The session featured key perspectives from leaders in the provider, accreditation, and technology spaces.
There was huge progress made with electronic prior authorizations (ePA) in 2017 and even further progress is expected this year, according to panelist Ron Fine, RPh, vice president, National Pharmacy Accounts, CoverMyMeds.
This expansion was largely set in motion in 2013 when the NCPDP created standards during a time in which no ePAs were being used. Fine said that only 4 years after the guidelines were created, use of ePAs skyrocketed to 70%.
Although traditional PAs still exist, ePAs offer benefits to both patients and providers, such as reducing time to fill and streamlining processes. Several challenges exist, however, regarding the medical benefit coverage for home infusion and specialty drugs, according to Fine.
From a provider perspective, payers have been eliciting more control in the specialty and infusion space in the recent past. This push is likely to continue into 2018, panelist Daniel Blakeley, CEO, Foundation Care, said during the session. Payers are not only making key decisions about which patients can receive which treatments, but also margins that can be developed around that.
Blakeley provided an example of a transaction in which his pharmacy administered a treatment to a patient with cystic fibrosis and, depending on the payer, lost anywhere from $1 to $1000 on the transaction. The frustration lies in the fact that a handful of pharmacy benefit managers control a majority of plans, meaning that pharmacies cannot afford to push back or risk dropping out of that network.
“Finding someone at that payer that you can discuss logically with and share with them actual invoice costs of what you pay for drugs, in some cases, it’s been helpful,” Blakeley said.
Sharing this information with payers may increase flexibility in certain situations and help them understand the situation better.
Tim Safley, MBA, director, DMEPOS, Pharmacy and Sleep, Accreditation Commission for Health Care (ACHC), mentioned several accreditation trends in the home infusion and specialty space during the session.
Safley discussed how ACHC is constantly educating payers and manufacturers about the value of accredited pharmacies or infusion providers. Payers have also been increasingly reaching out to ACHC to inquire about the distinction between different accreditations and accreditors.
Into 2018 and beyond, a significant trend Safley pointed to is that that more specialty pharmacies are seeking home infusion accreditation. Additionally, many long-term care pharmacies are inquiring about specialty accreditation in order for payers to grant them access to specialty drugs.
This crossover may add additional layers of complexities for pharmacies that now have to start collecting and reporting data in a new way, according to the session.
Erik Halstrom, Vice President, Specialty Pharmacy Solutions Division, Managed Health Care Associates Inc, concluded the session by asking the panelists to outline their top concern in each of their respective spaces.
For Blakeley, the payer relationship remains at the forefront of concern in the provider sector. A fair reimbursement rate is crucial to success as a business.
“For all of us, those relationships with payers and having someone who can be your advocate inside of the organization, is extremely important,” Blakeley said. “We plan to spend more energy doing that.”
With more states implementing USP <797> requirements, infusion providers will likely need to ensure they are complying with the rules even if they think they are, according to Safley. This may be complicated further by USP <800>, he said.
Fine concluded that he expects nearly every pharmacy and every plan to implement ePAs in the near future and fully benefit from the technology.