New Analysis Associates Integrated Specialty Pharmacy With Lower Total Cost of Care

April 21, 2021
Brian S. Smith

Health systems individually have struggled to demonstrate improvements to total cost of care because, without data about patients they do not serve, they cannot define a comparison group.

A poster presented at the Academy of Managed Care Pharmacy (AMCP) 2021 virtual meeting highlights a new study that measures the impact of integrated specialty pharmacy on the total cost of health care. Conducted by Shields Health Solutions (SHS) in conjunction with Optum Advisory Services, the study found that risk-adjusted per member per month (PMPM) costs were 13% lower for the intervention group compared to the control group.

Health systems individually have struggled to demonstrate improvements to total cost of care because, without data about patients they do not serve, they cannot define a comparison group. In addition, specialty pharmacy patient populations are quite small, at less than 2% of all patients.

This actuarial study presented at AMCP, the first of its kind at this scale and on this topic, was able to surmount these obstacles by utilizing Optum’s proprietary, de-indentified Normative Health Information claims database and by aggregating data from SHS network specialty pharmacies.

One of the study’s authors, Dale Fasching of SHS, notes, “By aggregating the SHS network specialty pharmacies, we were able to generate enough patient volume to remove ‘noise’ from total health care cost comparisons.”

The other authors of the study are Brian S. Smith, also of SHS, and Sarah Hellems and James Davidson of OptumInsight, Pharmacy Advisory Services. The title of the poster is “Association of Use of the Integrated Specialty Pharmacy Model on Total Healthcare Cost.”

A team from Shields Health Solutions and OptumInsight presented “Association of Use of the Integrated Specialty Pharmacy Model on Total Healthcare Cost” at the AMCP 2021 virtual meeting. Click HERE to view the poster.

Study Methods

The database was used to identify patients who 1) were enrolled in a Medicare Advantage plan, 2) had pharmacy insurance coverage in 2018 and 2019, and 3) filled at least 1 prescription for a self-administered specialty medication in 2018. Specifically:

  • Data on patients who filled self-administered specialty medications, as defined by specialty drug list, for 6 different disease states, were isolated.
  • Patients were followed over 2018 (baseline year) and 2019 (follow-up year).
  • Only Medicare Advantage patients were used, since both SHS and other pharmacies can fill medications for this patient subgroup, under Any Willing Provider rules.
  • Data were further refined to include only patients who had health plan (pharmacy and medical) coverage over the entirety of the study duration.

Patients were broken into 2 distinct groups:

  • SHS patients: Those who filled at an SHS-associated pharmacy AND had a doctor utilizing telemetry (meaning they were associated to the liaison workflow), and therefore received the full benefit of the integrated specialty pharmacy.
  • Network Benchmark patients: Those who did not have a prescriber utilizing telemetry and did not fill specialty medication at a SHS pharmacy (but filled their specialty medication elsewhere). This means these patients had the least exposure to the integrated specialty pharmacy care model.

Total cost and cost sub-components were tallied by patient and then weighted (adjusted) by CMS-HCC (Centers for Medicare & Medicaid Services Hierarchical Condition Categories) risk score, a standard actuarial method.

Study results

In the follow-up year, SHS patients—those who received the full benefit of the integrated care model—had lower total health care cost by 13% (>$1000 PMPM improvement).

Specific drivers of improved cost were challenging to examine, given the small number of specialty patients; however, oncology was an area in which SHS group patients saw improved adjusted medical expenses. Additionally, adjusted visits were improved in the SHS and Provider Benchmark groups against the Network Benchmark group, which might suggest that pharmacy care model interactions can replace expensive visits.

This study shows that specialty pharmacy care models, and in particular SHS’s integrated pharmacy model, can reduce total health care costs.

Among the study’s conclusions is a recommendation to repeat the analysis with the use of 2020 data. The inclusion of the additional year of data will result in a larger SHS-affiliated member sample and allow for further analysis and validation of the observed cost and utilization trends.

In addition, further analysis into specific disease states is needed to understand any emerging trends and whether the mix of drugs dispensed at specialty pharmacies impacts the average pharmacy cost and overall health care costs for patients. Fasching says that SHS plans to continue “to investigate how particular patient groups, and patient groups who receive particular care engagements, are associated with health care cost improvements.”

SHS partners with hospital leaders on every aspect of hospital-owned specialty pharmacy creation and growth. To date, SHS has partnered with more than 60 health systems in 43 states, and in January 2021, SHS acquired ExceleraRx Corp. to create the largest health system specialty pharmacy network in the United States.

Brian S. Smith is the Chief Pharmacy Officer at Shields Health Solutions, the nation’s leading health system specialty pharmacy integrator.