This dynamic market is seeing a lot of growth, changes, and challenges. Specialty pharmacists can tackle the tough issues and raise the bar on greater levels of efficiency, accountability, and service while curtailing costs.
Remember when you used to attend pharmacy conferences and only a few of the presentations were focused on specialty pharmacy? As time passed, more emphasis was placed on specialty pharmacy, but the topics were focused on the definition of specialty pharmacy, the pipeline, and the specialty pharmacy portion of the total US drug spend. It almost seemed as though all that was needed to prepare for the future was a good projection of what the market would eventually look like.
Well, here we are in 2012 and the specialty pharmacy industry has come a long way in what seems like a very short time. The need for change in this dynamic and ever-changing health care environment is continuous. Today, specialty pharmacies are being asked to provide much greater levels of efficiency, accountability, and service, while all stakeholders are looking to curtail costs. There are some who would even go so far as to suggest that specialty pharmacy services have become commoditized.
Commodity = Similar Reimbursement Discounts Plus Indistinguishable Customer Service.
However, from a specialty pharmacy perspective, all is not doom and gloom. Several specialty pharmacies are beginning to emerge and successfully position themselves by truly understanding customer needs and preparing for the future. In fact, the successful specialty pharmacy of today has launched a new “brand” and service model—one of accountability
, both critical components in maintaining a best-in-class position.
Accountability and collaboration are becoming much more prevalent within our practice. There are, in fact, specialty pharmacies today that have adapted and integrated these brands at a higher level within their Standard Operating Procedures. Those who have done so are thriving and have further cemented their place in the market as best in class. Those that have chosen to ignore or avoid these traits are definitely feeling the opposite effects.
Specialty pharmacies must confidently and effectively report on how they provide specific services, thus raising the bar in accountability, along with balancing a focused effort of collaboration. Examples of accountability and collaboration can be best described at the following stakeholder levels:
Health Care Providers
Specialty pharmacy patients have been confronted with a condition that has dramatically impacted their life and the lives of those around them. It is essential that specialty pharmacies keep this in mind as they serve them. A culture that provides balance will serve the patient well and enable the delivery and management of a complex and difficult regimen by keeping it “simple and real.” Specialized conditions require specialized care that should not result in additional burden for the patient and caregiver.
The new brand of specialized patient care mandates that patients and caregivers receive prompt attention and assistance. Access to assistance should not be hindered by a multioptioned telephone system that requires listening to a lengthy menu and selecting options. Patients need to speak with a person who can offer immediate assistance and service.
One recent example of personalized patient care at Amber Pharmacy follows:
“A patient undergoing chemotherapy treatment mentioned that for several hours after treatment, the sound of a ringing telephone would trigger an onset of nausea and vomiting,” said Kristi Admire, Amber Pharmacy’s patient education and resources program manager. “Our patient care platform is flexible to meet the patient’s needs. I simply indicated to the patient’s team when it would be a good time to call the patient. The platform is extremely efficient and truly allows us to offer personalized patient care.”
“Within Amber Pharmacy’s patient experience, we have taken the time to listen to our patients as well as the caregiver,” said Rob Else, Amber Pharmacy’s director of technology and programming. “This approach has allowed us to develop our proprietary platform to better manage a patient’s health care needs. To offer flexibility around what is important for the patient and their loved ones is a true differentiator.”
In summary, having the ability to document and to track a patient’s experience is a must. A platform that has the ability to highlight what is most important for the patient and caregiver helps achieve and maintain a successful regimen. It provides a level of personalization that may, in fact, become a standard of care in tomorrow’s specialty pharmacy suite of service offerings.
HEALTH CARE PROVIDERS
The needs and expectations of health care providers are rapidly changing. Communication and collaboration among all members of the health care team are essential to quality care. Improved collaboration and additional access to patient information ensures that the focus remains on wellness and improving patient care. “It’s really about minimizing any and all gaps in communication between patient, health care provider, payer, and specialty pharmacy,” states Lacey Deterding, PharmD, Amber Pharmacy’s lead pharmacist for hepatitis C virus (HCV) treatment. “It is becoming more and more prevalent that each provider asks for something a little different when it comes to open communication and the management and treatment of their patients.”
Today’s triple therapy regimen for treating patients with HCV offers insight into the need for increased collaboration and accountability. Providers quickly determine which specialty pharmacy is best in class and refer their patients directly into their management system.
Helping patients maintain compliance is a challenge due to harsh side effects. Amber Pharmacy’s dedicated HCV team provides patients with an individualized “pre-treatment” telephone consultation that lasts on average about 30 minutes. “All aspects of what to expect are covered,” states Dr. Deterding. “We proactively review all potential side effects of each medication and what to do if the side effects occur. We go over all medications—when and how to take them—in detail. Our program has proven successful in part because our patients have a comprehensive understanding of their treatment and the commitment needed for a successful outcome.” Amber Pharmacy’s approach clearly exemplifies how and why a program within a specialty pharmacy MUST be an extension of the provider’s care.
Smaller to mid-sized, self-insured employer groups are asking more questions regarding employee drug spend, particularly specialty drug spend. At Amber Pharmacy, we have experienced this scenario many times. A representative of an insurance company reviews the current medical plan offered to employees with the employer group. A past employee prescription expenditure and utilization list would show top line costs associated with statins, bisphosphonates, narcotic analgesics, etc. Today’s review will likely have a few specialty items on the top-line with equal if not greater costs. Employers want to know how costs are being controlled—and rightfully so.
If employer groups are asking more and more questions with regard to specialty medication utilization, we need to listen. What are the service expectations? What are the financial expectations? And equally important, what should they expect in the immediate and long-term future?
Payers are seeking greater access to specialty pharmacy patient management systems and more flexible reporting capabilities. Their clients are demanding outcome-oriented results, and payers need to demonstrate the value of specialty pharmacy services to remain competitive. Today’s specialty pharmacy can show results of therapeutic outcomes based on drug management, especially if it is comparative to their overall population. Having the ability to work with a health plan to integrate medical utilization and develop a specific area of management ultimately defines a collaborative approach. True collaboration for clinical outcomes would be the specialty pharmacy, payer, and manufacturer working together to collect, analyze, and benchmark activities.
Another point of collaboration is the Medicare Plan Star Ratings (MPSR), which were introduced as part of the Affordable Care Act. The ratings measure the quality and performance of health plans in 5 different categories that contain distinct measures. The health plan categories are:
Staying Healthy: Screenings, Tests, and Vaccines
Managing Chronic Conditions (specialty pharmacy can have an impact here)
Ratings of Health Plan Responsiveness and Care (specialty pharmacy can have an impact here)
Health Plan Member Complaint Service The stand-alone drug plan categories are:
Member Complaints and Staying with Drug Plan
Member Experience with Drug Plan
Drug Pricing and Patient Safety Plans receive a star rating for each category and every individual measure within the category. A contract can receive ratings between 1 and 5 stars:
* means poor performance
** means below average performance
*** means average performance
**** means above average performance
***** means excellent performance
The Affordable Care Act introduces quality bonus payments into the Medicare Advantage program as part of the national strategy for implementing quality improvement in health care. Beginning in 2012, quality bonuses are paid to Medicare Advantage plans that earn 4 or more stars in the 5-star quality rating system. As a result, the need for collaboration and accountability between specialty pharmacies and payers has never been greater.
Collaboration between health plans, that is, drug plans with contracted specialty providers, must be acknowledged in order for the payer to achieve the highest star rating possible. This incentivized approach mandates the need for superior knowledge and management of com- plex conditions. Specialty pharmacies can be key players in guaranteeing a health plan’s success by ensuring appropriate use of medications and reducing medication-related adverse events.
A specialty pharmacy’s ability to acknowledge and support best-inclass approaches to achieve a 5-star rating for a health plan cements a long-term relationship.
Even the most seasoned and wellestablished manufacturers are entering into newer markets due to pipeline launch expectations and/or acquisitions. Through collaborative opportunities, niche specialty pharmacies are becoming increasingly valuable to manufacturers by providing assistance with the successful launch of a new product. Specialty pharmacies understand their markets best and can offer honest and direct insight to a manufacturer. Collaborative opportunities include:
Provide insight and feedback on health care providers’ reactions to a REMS program
Share information from a specialty pharmacy perspective on the all-encompassing support necessary for a new-to-market product
If the patient is enrolled in a pharmaceutical manufacturer–sponsored support program, align and modify the patient care program offered by the specialty pharmacy. This is done to specifically define who is managing the patient, make certain the patient does not receive too many points of contact, and ensure no duplication of services
Data collection and reporting
Managed care contracts: Does the specialty pharmacy have access to restricted specialty networks?
Manufacturers are increasingly looking at specialty pharmacies to provide HUB-equivalent services. Reasons include service expectations, market expertise, and cost. This provides a unique opportunity for specialty pharmacies to maintain access to limited distribution networks along with keeping the door open for other opportunities as other medications prepare for market launch.
There is a lot of growth, change, and challenge in the specialty pharmacy market. More importantly, there are significant opportunities. While this is by no means a comprehensive review of ideas to increase collaboration and accountability, hopefully this information will inspire and spark ideas about how to improve the chances for success in such a dynamic space.
About the Author
Michael R. Agostino, RPh, BSPharm, is the president of Amber Pharmacy, an independent, family-owned provider of specialized pharmacy services headquartered in Omaha, Nebraska, with satellite locations in Dallas, Philadelphia, and Chicago. Mike is also president of Hy-Vee Pharmacy Solutions, an innovative joint venture between Amber Pharmacy and Hy-Vee, Inc. Previously, he worked as the vice president of managed care sales for the Walgreen Company where his responsibilities included operations, sales, business development, small business solutions, contracting, and client services. Mike specializes in the ability to turn around business performance, expand customer relations, increase sales and profit, optimize organizational productivity, and create innovative and entrepreneurial product programs and business models. Mike holds a bachelor of science pharmacy degree from Northeastern University. He serves on several boards including the board of advisors for
Specialty Pharmacy Times and several nonprofit, economic, and community organizations.
About Amber Pharmacy
Amber Pharmacy is considered a pioneer in providing high-quality clinical care combined with the support and counseling needed to treat complex medical conditions. Owned and operated by the Kaplan family, Amber Pharmacy is currently in its 15th year of operation. Amber Pharmacy provides comprehensive services for chronic health conditions, including transplant, oncology, hepatitis C virus, rheumatoid arthritis, multiple sclerosis, and most chronic conditions. The company is accredited by the Accreditation Commission for Health Care. Amber Pharmacy’s Promises Programs provide condition-specific management programs and complete customer care for patients, caregivers, family members, and providers. This comprehensive approach results in greater compliance, improved patient outcomes, and lower overall health care costs for plan sponsors and participants.
About Hy-Vee Pharmacy Solutions
Hy-Vee Pharmacy Solutions is a joint venture between Hy-Vee, Inc, of Des Moines, Iowa, and Amber Pharmacy of Omaha, Nebraska. Hy-Vee Pharmacy Solutions provides a comprehensive approach for patients—high-quality clinical care combined with the support and counseling needed to treat complex medical conditions. The company provides greater capacity, convenience, and accessibility at Hy-Vee Pharmacy service locations.