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5 Ways Health Systems Are Missing Out by Not Addressing Specialty Pharmacy

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5 Ways Health Systems Are Missing Out by Not Addressing Specialty Pharmacy

Specialty pharmacy remains a growth and patient care opportunity for large health systems (i.e., academic medical centers, integrated delivery networks, and community-based hospitals). Not only can they improve care and enhance continuity of care to the patients they serve, but also increase revenue streams and satisfaction among patients and physicians, while reducing risk in a value-based reimbursement model.

Operating a specialty pharmacy is a great benefit to a health system that adopts it early, while those who wait are going to face higher risks and lower probability of success.

Here are five ways health systems can be impacted by not opening an integrated specialty pharmacy:

1. Missing Out on Better Patient Care

While third-party pharmacies fulfill delivery of specialty medications to patients, they reduce the ability for physicians to easily monitor and track the patient’s health, making it harder to offer the highest possible quality of care. Where this becomes especially important is continuity of care and management of side effects or new symptoms. Without the benefit of real-time transparency that a shared electronic health record (EHR) provides, it becomes more difficult to manage and intervene in patient care complications and prevent a readmission or visit to the emergency room.

Working through a health system specialty pharmacy may not always feel the most comfortable to patients, as many associate hospitals are critical care settings. While it may feel more familiar to go to an offsite specialty pharmacy, it’s not always easier for patients. With physicians and pharmacists working together through an on-site pharmacy, they can provide education and management of medication while proactively adjusting treatment based on side effects and focus on increasing adherence.

Integrated specialty pharmacies at health systems give physicians and the multidisciplinary care team of pharmacists and nurses better access to their patients’ records. This allows them to better manage and monitor their patients’ compliance and persistence of use for prescribed medication. The ability to impact adherence of patients saves health systems money and results in healthier patients with less medication-related complications.

2. Preparing for Value-Based Reimbursement

Health systems and hospitals are now seeing their profitability directly tied to patient outcomes due to the transition from fee-for-service to value-based reimbursement. Transferring the pharmaceutical care of patients to commercial specialty pharmacies gives up control over the total care of a patient, which increases the risk to the health system. If a patient sent to an outside specialty pharmacy does not adhere to their medication regimen and is readmitted to the health system, then the cost for the interventional care comes without any additional reimbursement to the health system. This also results in reduced quality of care for the patient.

Health systems moving to a fee-for-value model and accountable care organizations (ACOs) are in alignment with payers around financial incentives. Outside specialty pharmacies, organizations incentivized to fill the most prescriptions possible, are not aligned with this system. Specifically, this makes the health system and ACOs responsible for any difference in allocated cost from capitation or reimbursements if the outside specialty pharmacy charges more than allocated for the medication.

Establishing an in-house specialty pharmacy is a win-win for health systems because it provides greater control over managing the patient. Adherence and the impact on readmission are vital to the health systems viability in a value-based care model.

3. Decreased Access to Specialty Drugs

Specialty medication and limited distribution drug growth are projected to account for half of all drug sales by the end of 2020, according to the National Association of Specialty Pharmacy. As more specialty drugs are developed and added into a limited distribution channel, it becomes harder for a traditional hospital pharmacy to access the medication their patients need. Integrated specialty pharmacies give patients access to the specialized drugs they need on-site more quickly, often on the same day of their visit with the physician at the specialty clinic.

If health systems don’t start taking the steps required to implement a specialty pharmacy now, they could be boxed out of the opportunity in the future as the competition in the specialty pharmacy space grows.

While implementing a fully integrated specialty pharmacy requires a meaningful investment, many health systems are starting with a basic model that includes one or two more familiar therapies to gain access to preferred channel drugs, such as Hepatitis C medication. This allows for additional revenue immediately that can be invested in a more robust specialty pharmacy over time.

4. Lower Patient and Physician Satisfaction

The lack of an integrated ambulatory specialty pharmacy can result in lower satisfaction across the board, from providers to patients. Without an integrated health system specialty pharmacy, it means that physicians have trouble giving their patients the pinnacle of care they strive for. This also creates an extra burden on their position of treating these specialized disease states that are often chronic and severe.

Not only can physicians become frustrated, but patients feel less satisfied if they feel their care is compromised or can’t get the answers they need from an off-site pharmacy. Additionally, patients face increased adherence complications from a non-integrated pharmacy, and they also don’t get the same amount of collaboration and follow-up with both their physician and pharmacist.

Lower satisfaction from both patients and doctors can make a health system less competitive, and less attractive for future referrals and provider expansion. While this is not at the forefront of problems in the healthcare industry, it is something that will have a more significant impact as specialty pharmacy continues to grow and both patients and doctors have more choices between other established ambulatory/specialty pharmacies.

5. Lower Profitability

As stated above, specialty drugs will make up 50 percent of all medicine spend by 2020. These drugs are increasingly becoming part of how health systems are staying profitable.

Not integrating specialty pharmacy increases the financial risk for health systems and allows competitors to take a larger market share. The revenues from specialty medications can be a significant help to hospitals and provide them with additional financial margins to improve the quality of care across the board.

Conclusion

Health system specialty pharmacies are becoming an increasingly important factor in determining profitability and competitiveness with health systems and hospitals. Specialty medication continues to expand in the market and will continue to impact the ability to offer quality and continuity of care. If you have not yet considered integrating a health system specialty pharmacy into your organization, now is the time to evaluate and act.
Pedram Pahlavan
ABOUT THE AUTHOR | Pedram Pahlavan
As a Senior Director of Specialty Pharmacy, Pedram develops, implements, and maintains a health system centric specialty pharmacy solution.
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