Specialty Pharmacy Data Standards in a Rapidly Evolving Value-Based World

Specialty Pharmacy TimesFebruary 2020
Volume 3
Issue 1

Specialty medications also are the fastest growing cost component of total health care costs.

The multidimensional Triple Aim, developed by the Institute for Healthcare Improvement in 2008, emphasizes the concurrent goals of improving the individual patient-care experience, improving the health of a population, and reducing per capita costs of care for populations. In 2010, the Triple Aim became a foundational element for US-based health strategies, emboldened by the implementation of the Patient Protection and Affordable Care Act (ACA). At the time, the Triple Aim was a radical idea and its success would require major behavioral changes from payers, pharmaceutical and biopharmaceutical manufacturers, providers, and patients. Noticeably absent from the early discussion was specialty pharmacy.

Current State

Fast forward to 2019, and the Triple Aim and value-based payment models are intricately woven into our everyday health care lexicon. Value-based contracting, and its emphasis on reimbursement—based on meeting or exceeding defined quality and outcome measures rather than fee-for-services—is primarily a relationship between payers (ie, Medicare, Medicaid, commercial companies, and plan sponsors), providers (physicians, accountable care organizations, and integrated delivery networks), manufacturers, and patients. Again, specialty pharmacy is noticeably absent.

By most accounts, specialty medications will soon make up at least 50% of all US-based prescription-drug costs, even although they are used by a disproportionately small number of patients representing 3% to 5% of the total patient population. Specialty medications also are the fastest growing cost component of total health care costs. The combination of this trend and a robust product pipeline will ensure that specialty drugs and associated care costs will continue to be a prominent target of payers seeking to lower overall health care costs.

Specialty medications are predominantly dispensed through specialty pharmacy, which has direct responsibility for medication-related patient care management. The question that remains is whether specialty pharmacy will achieve key “stakeholder” status with an opportunity to influence policy and reimbursement or continue to be noticeably absent in a rapidly evolving, value-based Triple Aim world.

A Path Forward: Specialty Pharmacy In An Evolving Value-Based Triple Aim Environment

Specialty pharmacy often touts its ability to provide high-touch patient personalization during a patient’s journey on specialty medications. What seems to be missing is real-world data showing how effective and valuable that patient personalization is.

The table provides some examples on specialty pharmacy data-driven value-based opportunities:


Triple Aim Dimension

Specialty Pharmacy Data-Driven Opportunity

Data Elements

Improving the individual patient experience of care

  • Using a patient’s preferred form of communication, introduce proactive medication-surveillance outreach with the right frequency at a time most convenient for patient.
  • Instantaneous response for any patient-reported logistical, clinical, or financial issue
  • Immediate assignment of patient- reported issue to designated team member with escalation provisions until the issue is resolved

  • Patient-preferred mode for primary communications, eg, text, voice, web, or virtual assistant
  • Patient-specific preference for type of communications and their frequency and duration
  • Time stamps on engagement prompts sent, received, read, and responded to
  • Exact elapsed duration between patient’s issue or concern and its resolution by the pharmacy

Improving the health of populations

  • Using consistent evidenced-based patient care management guidelines that are disease or drug specific
  • Proactive patient-engagement prompts without restrictions to messaging, frequency, or duration
  • Using communication technology that enables the patient to easily respond in a conversational manner rather than simple yes or no responses
  • Capture actual patient medication start and stop dates in addition to standard ship date-based adherence measures, eg, proportion of days covered (PDC) or medication possession ratio (MPR).

  • Detailed patient-reported responses to drug- or disease- specific care- management prompts
  • Patient-reported issues and/or free text responses categorized by type (logistical, clinical, financial)
  • Patient-reported start, stop, and restart dates
  • Nurse or pharmacist communications and interventions by frequency, type, and outcome

Lowering overall health care costs

  • Improve care coordination with providers with notifications of patient-reported issues, resolutions, or recommendations.
  • Reduction or prevention of adverse effects and events
  • Improved health care outcomes (eg, reduced emergency department visits and hospitalizations) associated with higher-touch care

  • Time stamp of proactive provider notifications
  • Provider responses to pharmacy notifications
  • All pharmacist and nurse interventions with patients or providers and outcomes

Developing Specialty Pharmacy Data Standards For A Value-Based World

Specialty pharmacy accreditation organizations such as URAC, the Accreditation Commission for Health Care, the Center for Pharmacy Practice Accreditation, and The Joint Commission have effectively established baseline data-driven standards for operational, administrative, and some clinical outcome measures. The National Council for Prescription Drug Programs and the Pharmacy Quality Alliance are leaders in establishing baseline standards for electronic data interchange and consensus-based measures for medication safety, adherence, and appropriate use. These standards are the foundation for accreditation organizations’ baseline data and measure their requirements.

New standards that capture the myriad steps involved in proper patient outreach, monitoring, feedback, and issue resolution will be required. Telephone-oriented standards measuring average hold times for patients are no longer enough. Using the standards provided by the above-named organizations, and possibly others, would be a good start.

Great, How Do We Pay For This?

This is an excellent question in an era of declining drug margins. Research into 25 specialty pharmacies indicates that most specialty pharmacy and patient communications occur via the telephone. Telephonic exchange with patients can create a personalized experience; however, it is a high-volume, high-cost journey that relies on making a connection, which is not always possible. Technology-enabled solutions, however, can significantly reduce low-value telephone outreach and calls, and augment high-value telephone exchanges to drive measurable valued outcomes. These technologies, if used properly, can help improve staffing pressures by preventing redundant calls and improving response times. In addition, patient engagement can be improved and used to drive desired clinical outcomes.

There are many technology vendors that provide standard text messaging, mobile apps, or web-based portals. But these have a minimal impact on reducing operational costs and lack the breadth and depth of clinical and operational expertise that reflects the nuances and complexities of patients who are on specialty medications.

Instead, it is critical to seek out a technology vendor that fully understands specialty pharmacy, including its unique workflows; the relationship between dispensing systems and clinical management systems, and members and patients; and the dynamics of payers and manufacturers. The vendor also must have a mission of driving down costs to fill.

The solution should create a positive return-on-investment, be easy to implement, create minimal workflow disruption with the flexibility to grow. It should also meet evolving value-based Triple Aim measures.


Results from a recent American Journal of Managed Care study showed that manufacturers and payers entered into 100+ value-based contracts in 4 years. The authors noted that value-based contracting was likely even more prevalent because a majority of value-based contracts are not publicly disclosed.

The Centers for Medicare and Medicaid Services, a payer of considerable influence, has paved the way for reimbursing pharmacy medication therapy management services for Medicare Part D beneficiaries.

The value-based Triple Aim movement is undeniable. Specialty pharmacy has the opportunity to shape the dialogue on the measurable value of its services, particularly on patient outcomes, in a value-based world. The opportunity window is open, but it is small and will be closed before we know it.


Mahendraratnam N, Sorenson C, Richardson E, et al. Value-based arrangements may be more prevalent than assumed. American Journal of Managed Care. https://www.ajmc.com/journals/issue/2019/2019-vol25-n2/valuebased-arrangements-may-be-more-prevalent-than-assumed Published February 13, 2019.

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