Health systems and manufacturers need to work together to obtain inclusion for health system specialty pharmacies so that patients can fill their prescriptions within a coordinated care ecosystem.
Caring for patients with complex diseases is inherently challenging. When specialty medications are prescribed, informing and educating the patient about their disease state and treatment plan is only part of the puzzle. Behind the scenes, you need a team that works with the patient and other stakeholders to ensure drug coverage, secure financial assistance, and monitor the patient’s medication adherence and tolerance.
However, when these services are performed by the health system specialty pharmacy team, who are informed by the electronic health record (EHR) and are part of a larger interdisciplinary team, they ensure a seamless patient experience, whether or not the health system fills the prescription. When care coordination is lacking, patients facing the burden of a disease must also jump through hurdles and contact various stakeholders just to access their medication. Consider the story of Ms. Jones.
Considering the Patient Experience
Imagine that Ms. Jones is diagnosed with hepatitis C virus. First, her doctor prescribes a specialty medication and tells her that she will be contacted by a specialty pharmacy that will fill her prescription.
She receives a welcome call from the pharmacy but is informed that her prescription must be filled by the pharmacy benefit manager- (PBM) owned specialty pharmacy to receive in-network benefits. Her prescription is triaged to this pharmacy who informs Ms. Jones that they must verify her insurance coverage of the medication and obtain appropriate demographic, lab, and medical documentation required for a prior authorization (PA).
The pharmacy faxes the doctor’s office to request this information, and the doctor’s office and the pharmacy play phone tag, because the practice has staffing challenges and limited resources who can respond to the request.
Once the PA is approved and the prescription is adjudicated, the pharmacy contacts Ms. Jones to tell her the co-pay of her drug, which Ms. Jones cannot afford. The pharmacy informs her about patient assistance programs that may make the care plan financially feasible.
To determine her eligibility, Ms. Jones must give consent to process her application and be enrolled in the program by signing the paperwork and scanning or faxing it for processing. The entire process may take a week or more, further delaying first fill of the medication. This is clearly not the best solution for Ms. Jones, who is anxious to start treatment.
The Empirical Case for Health System Specialty Pharmacy
Contrast Ms. Jones with Mr. Long, who has access to a health system specialty pharmacy (HSSP). Mr. Long meets face-to-face with a pharmacy representative at the end of his appointment who can help him better understand the drug he was prescribed and provide him with a single point-of-contact who ensures care coordination. The pharmacy representative, physician, and other members of the care team are part of the same health system, so they can more easily work together and can directly reference his EHR to proactively avoid delays related to insurance, PA, and treatment costs.
Although Mr. Long’s prescription must also go through PA, these efficiencies ensure that the prescription is filled as rapidly as possible, allowing Mr. Long to receive his medication in less than a week. What’s more, the pharmacy team regularly follows up with Mr. Long to ensure he is taking his medication and has support for adverse effects or other treatment challenges, and they record those touchpoints in his EHR to share with his provider.
This enhanced level of communication can lead to better cure rates and/or outcomes. In summary, HSSPs offer an unmatched level of coordination that benefits the patient:
Freeing the patient to communicate less: With all members of the HSSP care team having immediate and full access to the EHR, the patient does not have the burden of communicating all relevant details as they would to a third-party specialty pharmacy. Pharmacies outside of the health system leverage clinicians who typically rely on phone-based interactions and assessments to extract information about the patient’s status. As one patient put it, “…the hospital specialty pharmacy experience has been better because they know more about me, my disease, and my treatment.”
Fully supporting the patient in dynamic situations: The HSSP care team has the visibility to see across the treatment spectrum and can act proactively, rapidly and knowledgeably in complex and dynamic situations. For example, a patient may be working with multiple specialists and treatments and may experience ongoing changes or hospitalizations due to disease progression and treatment response. The health system care team, including the HSSP, provide better patient support because of immediate and full visibility into the factors that influence access, adherence, and outcomes.
Providing a greater range of patient solutions: Because of the collective services offered by the health system, when issues or unique patient situations arise, there are a greater range of options available to support the patient. A cancer patient described it this way, “…there are different resources at different times that have to step up, and knowing that they are there at my fingertips is really important.” Specialty pharmacies typically offer phone-based 24/7 clinical support to ensure patients can speak with a pharmacist; however, patients working with an HSSP have the additional option of face-to-face conversations and all patient and pharmacist interactions are integrated with other care. A patient with skin issues from adverse effects could easily speak with a pharmacist about current medications and just as easily schedule a next-day dermatologist appointment to explore additional therapy options.
Enabling Patient Choice
Although the benefits of HSSPs are clear, currently, to receive in-network coverage, most patients don’t have a choice about where they get their specialty pharmacy prescription filled. That decision is made by the payer or the PBM, which have their own specialty pharmacies or rely on a network of contracted specialty pharmacies on behalf of their members.
In a recent study conducted by CSI Specialty Group, 73% of manufacturers cited that they had given HSSPs access to a limited distribution product, but the other side of the equation—access to the payer network—needs to be resolved. Those same manufacturers said that their selection process was informed primarily by a specialty pharmacy’s access to payers. This conundrum needs to be addressed as manufacturers clearly recognize the value of the care HSSPs can provide, but payer access remains a challenge.
Manufacturers also called out several areas that specialty pharmacies need to improve. This included time to fill, communication, responsiveness, data services and reporting, flexibility, customer service and transparency. These areas are where HSSPs can shine. Time to fill for most HSSPs is typically 72 hours or less.
Any Willing Provider Laws and Evolving the Specialty Pharmacy Landscape
Specialty pharmacies that are seeking broad access can leverage Any Willing Provider (AWP) laws. These rules were established in 2005 at the federal level to ensure adequate access to drugs under Medicare Part D when dispensing limited distribution products.
The AWP provision under Medicare Part D requires Part D Prescription Drug Plans (PDPs) to allow pharmacies that meet the standard terms and conditions of the PDP to participate in-network. These standards are expected to be reasonable and relevant, and they may differ to account for diverse geographical areas and pharmacy types, as long as similarly situated pharmacies are treated the same.
AWP laws do not require PDPs to contract with all providers; however, the criteria for network pharmacies must be explicit, thereby giving AWP the opportunity to obtain in-network status. Although federal law generally outlines AWP requirements, individual states typically regulate their own insurance markets and individual PDPs set their own evaluation criteria.
As a result, AWP statutes vary from state to state, but they rely on guidance from CMS, which has the authority to review all items related to PDP compliance with the AWP requirement.
The availability of an increasing number of specialty drugs and the expansion of AWP laws at the state level (32 states have such laws in place) is contributing to a debate aboutâ€•and hopefully expanded access to—specialty products at a greater number of sites, including HSSPs.
Putting Patients First
HSSPs are uniquely positioned to provide coordinated care to patients through relationships with providers, shared access to the EHR, and a commitment to following through on a patient’s needs, regardless of whether they fill the prescription or not. The coordination leads to increased speed-to-therapy and an improved patient experience.
Manufacturers are now quickly understanding that HSSPs should be included in their networks as well, as they are a growing segment of specialty pharmacy; however, payers must also be convinced to include HSSPs, as they have been narrowing their pharmacy networks for ease of administration.
Health systems and manufacturers need to work together to obtain inclusion for HSSPs so that patients can fill their prescriptions within a coordinated care ecosystem.
About the Author
Kristin Chambers is vice president of Strategic Development, Integrated Health Systems Outcomes Coalition, part of AmerisourceBergen.