Tips for Managing the Specialty Pharmacy Payer Environment

It’s projected that by 2021, specialty drugs will make up more than 40% of the pharmaceutical pipeline, with an estimated industry value of $240 billion. For organizations offering specialty pharmacy services, this translates into a constantly evolving need for obtaining and nurturing relationships with payers. Consequently, these contracts and relationships are also often cited among a specialty pharmacy’s biggest struggles.

With the rapid growth of the market, payers strive toward value-based care models to optimize outcomes and costs. As a result, payers continuously challenge specialty pharmacy networks to prove their value.

For specialty pharmacies to keep up, proving value isn’t just about reporting – it’s about weaving value-based and outcome-based strategies into the core of their operations, and exploring new opportunities to expand or shift their service dynamics to meet payer needs.

Payer Outlook and StrategiesManaging the Specialty Pharmacy Payer Environment blog-02

A 2013 report revealed that specialty drugs on average cost 18 times more than branded prescription drugs, and 189 times more than generics. Into 2017, costs have continued to edge upward.

Taking these exponentially growing costs into consideration, it’s no wonder that payers are constantly evaluating the cost and quality of care, while establishing guidelines to ensure that specialty pharmacy medications are being prescribed appropriately and administered properly with minimal waste. To ensure this, specialty pharmacies are expected to follow a standardized care process that is capable of optimizing outcomes and  ensuring patient safety.

Narrowing and “Preferred” Networks

For several years,  payers have  narrowed their specialty pharmacy networks and instituted the use of “preferred” networks. Payers, pharmacy benefit managers (PBMs), and health plans can require reliable, high-quality services by restricting access to their networks through pharmacy contracts. They’re better able to ensure that care is consistently managed, while maintaining an expected level of cost efficiency.

As a result, these competitive circumstances can create increased obstacles for hospital systems and independent specialty pharmacies attempting to secure contracts and gain market share.

Key Metrics for Proving Specialty Pharmacy Value

Key types of specialty pharmacy metrics include:

  • High-level metrics to measure adherence, such as whether patients take medication as prescribed and on schedule
  • Clinical metrics, including lab values, which indicate appropriate selection, use and efficacy of medications for each patient’s condition and genomic profile
  • Performance indicators of the pharmacy, such as patient satisfaction and how long it takes for pharmacists to process orders
  • Operational metrics, such as telephony measures and accuracy of fill rates which reveal performance in comparison to peers
  • Economic measures such as fewer ER admissions or side effects that required additional treatment
  • Humanistic measures such as those that provide key insights into the patient’s quality of life

Managing the Specialty Pharmacy Payer Environment blog-03Proving Patient Outcomes

Patient outcomes are a key indicator in the efficacy of a specialty pharmacy’s operations. Proving these outcomes to payers starts from the foundation of a specialty pharmacy’s services. Organizations should have the structure, processes, technology, and tools in place in order to standardize their work processes.  By eliminating process variation, they can collect, track, measure, quantify, analyze and report patient outcomes data with confidence.

Specialty pharmacy providers should optimize and standardize  the clinical care process internally, establish systems to quantify the number of patients who use their medications correctly, continuously hone systems to ensure adherence and implement interventions when needed, and measure long-term health changes in patients. Ideally, these tracking and measurement systems will be tailored to the disease states, to assist with specificity in reporting therapy outcomes.

Expansion of Services & Alliances

For increased competitive viability in securing and maintaining payer contracts, specialty pharmacy providers may wish to enhance or expand their services. Doing so may help align providers with payer criteria and preferences, while building and strengthening valuable industry relationships and networking opportunities. For example, a specialty pharmacy provider may decide to provide new services to improve patient satisfaction and/or demonstrate outcomes.  Actual examples include on demand patient training via video clips or sub-delegated prior authorization services for payors.

Therapy Management Software

Many hospital systems and specialty pharmacies are turning to therapy management software to ensure a level of organization, transparency, standardization and reliability that are not available through standard pharmacy dispensing systems.

A strong software platform will integrate systems and processes from patient intake to outcomes reporting, offering a centralized location for operations information. This helps to eliminate data siloes and the need for fragmented tools and systems for data collection, measurement, and reporting.

TherigySTM is a therapy management software that was designed to do just that – help specialty pharmacy providers centralize their operations and build a foundation for proving their value consistently and systematically. Learn more about TherigySTM to see if it’s the next step for your organization.