These facilities provide significant value to payers and patients.
There is an opportunity for pharmacists to improve care whenever they fill a prescription at the same health system in which the prescription was written, explained Jen Simpson, PharmD, an ambulatory clinical pharmacist with UVA Health Specialty Pharmacy. According to Simpson, the challenges that can arise from insurance companies requiring patients to get their specialty medication from a large, offsite mail-order pharmacy can be considerable for the patient.
“Anytime we can fill for a patient who hasn’t been able to fill with us before, it makes me happy because I know the patient will get better care from us,” Simpson said. “I see the opposite each time I have to correct issues for patients who can’t fill with us because they’re required to fill with a larger, outside specialty pharmacy.”
UVA Health Specialty Pharmacy is part of the University of Virginia Health System (UVA Health) in Charlottesville, which includes a 600-bed academic medical center, 3 community hospitals, and an integrated network of primary and specialty care clinics. In Simpson’s work at UVA Health Specialty Pharmacy, she cares for patients with inflammatory bowel disease. Notably, she is also an integral member of the clinical team in the UVA Health Digestive Health Clinic. Simpson has direct contact with patients and providers at the clinic as well as access to patients’ medical records via UVA Health’s electronic health record (EHR) system.
In the patient case of RH, Simpson explained that RH received ustekinumab (Stelara; Janssen Biotech), an injectable treatment for ulcerative colitis, under a new contract between RH’s insurance plan and the UVA Specialty Pharmacy. RH had experienced problems getting timely refills from the offsite mail-order pharmacy that his insurance plan previously required him to use.
With the offsite pharmacy, RH explained, he had to set his own reminders to proactively call the pharmacy for refills. When he called, he could be on the phone for as long as 20 minutes before he was able to speak with someone, and it would take an additional 10 to 15 minutes to complete the refill process. Sometimes, the pharmacy would give him an incorrect refill date, so he would call it in before it was due and not be able to obtain his refill. Because the offsite pharmacy would not process a co-pay card for him, RH had to pay the full co-pay when the medication was dispensed, then apply for a rebate from the drug manufacturer. Further, when the pharmacy did ship the medication to him, it was inflexible about delivery dates.
When RH was able to fill his prescriptions at the UVA Health Specialty Pharmacy, he had no issues getting refills in a timely manner, delivered to his home on dates he was able to request. He was also set up with a co-pay card by the UVA Health Specialty Pharmacy that significantly reduces the cost to him when his medication is dispensed, eliminating the need for him to seek reimbursement from the manufacturer.
“Our automatic refill program allows us to fill prescriptions for patients earlier, so they do not miss a dose, and it notifies us in advance when a prior authorization is needed for a refill,” Simpson said. “We also offer more detailed and thorough follow-up. We’re constantly checking in with patients to provide counseling and to monitor their medication through our pharmacy’s patient monitoring program. With access to the EHR, we can catch things, like lab work that needs to be done or potential adverse drug interactions. And we’re very easy to reach by phone. I provide all my patients with my direct contact info.”
For patient LM with ulcerative colitis, she was covered by the same insurance plan and complained about prior communication issues with the offsite specialty pharmacy. In this case, she was transferred to UVA Health Specialty Pharmacy as Simpson had already been working diligently to make sure there were no gaps with her medication.
“The patient is taking a non–FDA-approved frequency of ustekinumab, which the insurance plan denied and required an external review,” Simpson said. “After becoming involved over 2 years ago, each subsequent appeal has gone through the first time. We’ve been able to get her on the therapy and keep her on it.”
According to Joshua Weber, PharmD, MBA-HCM, CSP, director of specialty and home delivery pharmacy services at UVA Health Specialty Pharmacy, Simpson acts as an extension of the provider within UVA Health. “She sees these patients right in the doctor’s office where the order originates from,” Weber said. “Being directly connected with the doctor and the patient in the clinic and through the EHR allows her to make sure the patient is adhering to their medication and that they’re getting the intended value of the therapy, both clinically and financially.”
As health care moves toward a value-based care model in which reimbursement increasingly is tied to better patient outcomes at lower cost, hospitals and health systems must be able to show payers proof of the value of the care they provide patients. Health system specialty pharmacies (HSSPs), such as UVA Health Specialty Pharmacy, are medically integrated into their health system’s clinical care teams and are well positioned to demonstrate clinical value and decreased total cost of care to payers, explained Pedram Pahlavan, PharmD, BSP, associate vice president, Acentrus Specialty Pharmacy Program. According to Pahlavan, specialty pharmacies were created to coordinate care for patients on complex, often expensive medication therapies for conditions such as cancer, diabetes, multiple sclerosis, and inflammatory disorders.
“Because these specialty medication regimens may need to be adjusted based on the patient’s therapeutic response or adverse events [AEs], they often require close patient monitoring and education to generate optimal outcomes, avoid [AEs], and maximize [adherence],” Pahlavan said. “Pharmacists who are medically integrated into the clinical care team, who are onsite with the specialist prescribing the medication, are much more capable of optimizing therapy for these patients than pharmacists at a large, vertically integrated mail-order specialty pharmacy halfway across the country.”
One of the key advantages HSSPs have over larger, offsite specialty pharmacies is their direct access to the health system’s EHR. External specialty pharmacists typically have access only to claims and pharmacy dispensing data, which gives them a much more limited understanding of the patient’s clinical journey.
“Direct access to the EHR allows the pharmacist to see all the notes that the physicians and nurses have entered into the patient’s record, including the medical documentation required to expedite approval of prior authorizations,” Pahlavan said. “This helps verify the medical need and appropriateness of the therapy much more quickly, which, in turn, allows the patient to get on the therapy much more quickly—often within hours or days, rather than weeks.”
For patients who may be in shock after a diagnosis of a serious illness such as cancer, any delay in starting therapy can add to an already stressful situation and may adversely impact the patient’s clinical outcome, explained Pahlavan. Furthermore, the patient is not the only beneficiary. For providers, having the HSSP assume administrative functions like preparing the paperwork for prior authorizations and appeals and dealing with health plans allows the provider and other members of the team to focus on caring for patients.
Additionally, Pahlavan explained that HSSPs can benefit payers and plan sponsors by decreasing the total cost of care. This may include everything from reductions in hospital readmissions and emergency department visits because patients are more adherent to their therapies to more efficient and cost-effective medication usage resulting from better-managed splitfill programs. “Medically integrated specialty pharmacy can help avoid costs associated with waste, especially in complicated therapies like oncology, where drug dosages or the medication itself may need to be changed based on the patient’s response or if there is an AE,” Pahlavan said.
Pahlavan cited 3 studies to support this point. One study showed a potential average savings of $1800 per medication dose change at an HSSP compared with an off-site network pharmacy.1 The second, a retrospective study of similar cohorts of Medicare patients, demonstrated net savings of more than $1000 per patient per month for patients treated by a medically integrated pharmacy.2 The third study, which looked at Medicare Advantage patients prescribed oral oncolytic medications, showed estimated savings of approximately $900 per patient per month.3 HSSPs also consistently achieve higher net promoter scores from patients and providers, indicating greater satisfaction with the medically integrated specialty pharmacy model compared with larger, offsite pharmacies.4
“Improving medication…and therapy [adherence] is critical if we want to optimize the clinical effectiveness of the treatment and maximize the return on capital invested in these very expensive specialty medicines. There’s ample evidence to suggest that the superior care and…patient experience provided by medically integrated HSSPs cost no more than the services provided by remote mail-order specialty pharmacies and…drive down the total cost of care,” Pahlavan said.
Additionally, Pahlavan noted that the challenge facing many onsite specialty pharmacies and their advocates is convincing insurance professionals who are the decision makers in contract negotiations of the value of onsite specialty pharmacies. Specifically, that value can be seen for patients and payers.
One of UVA Health Specialty Pharmacy’s most effective strategies when seeking to negotiate new contracts with commercial payers is to link every intervention performed by the health system’s medically integrated pharmacists, such as Simpson, to improvements in outcomes.
“Tying these interventions that our pharmacists do [daily] back to improvements in clinical, financial, and administrative outcomes is crucial. It’s how we show value in partnering with payers,” Weber said during a presentation at the 2023 Acentrus Specialty Conference in April in San Diego, California.
Specific interventions highlighted by Weber include those performed by UVA Health clinical pharmacists during initial patient assessments, such as injection and medication administration training, drug interaction management, and extensive review of the patient’s medical record to determine any medication safety or efficacy issues. Other interventions performed during regular follow-up assessments include AE mitigation and management, interaction with the patient’s providers, medication adherence, and direct contact with the specialty pharmacy team responsible for obtaining prior authorizations and financial assistance to help keep patients on their therapies.
“These are the kinds of interventions vertically integrated mail-order pharmacies have a very hard time matching because their pharmacists are not connected in real time to either the EHR or to the providers, and because they have so many more patient lives to deal with. This gives us a competitive basis to focus on,” Weber said.
The daily interventions performed by its pharmacists have helped UVA Health Specialty Pharmacy achieve a greater than 85% medication adherence rate for patients enrolled in the specialty pharmacy program, which is a significant clinical benefit and one that larger vertically integrated specialty pharmacies cannot match, according to Weber. The UVA Health pharmacists’ interventions have also resulted in a prior authorization turnaround time of less than 24 hours in many cases and an 80% approval rate for appeals, demonstrating clinical and administrative improvements.
UVA Health Specialty Pharmacy can also demonstrate lower out-of-pocket costs for its specialty pharmacy patients as well as decreased waste of expensive medications—an important consideration for health plans, pharmacy benefit managers, and plan sponsors. Additionally, when negotiating with payers, Weber can cite multiple studies showing that HSSPs overall deliver reduced total cost of care compared with vertically integrated offsite specialty pharmacies.2
“If you can show that your specialty pharmacy offers better patient access and more affordable care, that’s a win for patients,” Weber said. “If you can show that your providers are spending less time having to do prior authorizations, they will be your biggest ally. If you can show plan sponsors that you are able to deliver a reduction in total cost of care, that’s a win-win all the way around.”
By demonstrating its ability to improve outcomes that are important to payers, UVA Health Specialty Pharmacy has been able to gain access to several large payer networks covering approximately 20,000 additional patients, according to Weber.
“Our vision at UVA Health is to provide accessible care for all patients so they can live happier, healthier lives,” he added. “We want payers to recognize that the service delivery model provided by medically integrated HSSPs are the way of the future and the way to drive that vision forward. And we want payers to come along with us on this journey.”
1. Prime Therapeutics finds $1.1 million waste reduction opportunity with medically integrated dispensing compared to central specialty pharmacy. Eagen, Minnesota: Prime Therapeutics; June 2, 2022. Accessed October 12, 2022. https://www.primetherapeutics.com/news/prime-therapeutics-finds-1-1-million-waste-reduction-opportunity-with-medically-integrated-dispensing-compared-to-central-specialty-pharmacy%ef%bf%bc/
2. Hellems SS, Soni A, Fasching D, Smith BS, McManus DD. Association between health system specialty pharmacy use and health care costs among national sample of Medicare Advantage beneficiaries. J Manag Care Spec Pharm. 2022;28(2):244-254. doi:10.18553/jmcp.2022.28.2.244
3. Staskon FC, Kirkham HS, Pfeifer A, Miller RT. Estimated Cost and Savings in a Patient Management Program for Oral Oncology Medications: Impact of a Split-Fill Component. J Oncol Pract. 2019;15(10):e856-e862. doi:10.1200/JOP.19.00069
4. Trellis Rx Achieves a Leading Patient Net Promoter Score in Zitter Insights’ Specialty Pharmacy Patient Satisfaction Survey. Atlanta, GA: Trellis Rx; January 28, 2021. Accessed October 12, 2023. https://www.businesswire.com/news/home/20210128005066/en/Trellis-Rx-Achieves-A-Leading-Patient-Net-Promoter-Score-in-Zitter-Insights%E2%80%99-Specialty-Pharmacy-Patient-Satisfaction-Survey
About the Author
Gary Hopkins is a principal with Blanco + Hopkins & Associates, LLC, a health care public affairs firm based in La Cañada, California.