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The correct approach to take when creating a specialty pharmacy network is a key issue for healthcare executives.
Approaches health plans take when thinking about creating specialty pharmacy networks, and how to improve upon those endeavors, are key issues for healthcare executives.
StrahlAt the AMCP Managed Care & Specialty Pharmacy Annual Meeting in Denver, Christine Strahl, PharmD, MBA, BPCS, senior manager, specialty pharmacy programs at HealthPartners, shared challenges to managing specialty pharmacies, and discussed the importance of creating a robust specialty pharmacy, during the March 28 session, “Creating a Robust Specialty Pharmacy Network - The Payer Approach.” She copresented with Sheila Arquette, executive director for the National Association of Specialty Pharmacy and pharmacy special projects advisor at Independent Health.
A robust pharmacy
Specialty medications cost about $5,000 a month and account for about one-third of pharmacy benefit costs, yet fewer than 1% of members with a pharmacy benefit use them, Strahl told Managed Healthcare Executive.
“This means that a limited number of drugs and claims are really driving the cost of insurance for drugs today and we need to be prudent in management of these costs,” she said. “Additionally, the pipeline of drugs in development is primarily focused on these types of drugs-driving estimates that a majority of pharmacy benefit spend will be in specialty drugs in the next several years. There are many specialty pharmacies and many other existing pharmacies who are also very interested in dispensing specialty medications.”
Health plans must consider both external and internal factors when determining what pharmacies to include in the network, according to Strahl. This includes “any-willing-provider” laws, which may require plans to allow all pharmacies to dispense specialty drugs, she said.
“Additionally, a health plan may not want to narrow their network if their competitors don’t,” Strahl said. “Internal factors include the desire to maintain relationships with local pharmacies and concern about negative perceptions from a narrow network.” She added that plans may want to dispense specialty drugs internally through their own pharmacy/pharmacies.
Specialty pharmacy defined
“Specialty pharmacies provide expertise in the management of these less-widely used drugs,” Strahl said. “They are also uniquely suited to dispense these drugs as the staff of the pharmacy has experience managing patients with the conditions that the drugs help. There are several commodity services that specialty pharmacies provide including benefit investigations and copay assistance support, 24/7 pharmacist availability, delivery to home, and monthly calls to set up the next refill.”
The differentiating services-clinical programs, waste management programs, delivery to retail locations, access to the care team or electronic health record, willingness to share risk and outcome reporting-may drive a health plan to select one specialty pharmacy over another, she said. “Obtaining the most services considered of value to the plan at the lowest cost is the sweet spot that plans are seeking for network partners.”
Next: Specialty pharmacy challenges
The challenges of managing a specialty pharmacy network vary based on the pharmacies in the network, according to Strahl.
“If you own your own pharmacy that presents an entirely different suite of internal challenges,” she said. “If you manage a network, then the more pharmacy partners, the more internal resources that may be needed. This includes informatics for reporting, account management, and contracting resources. Employ a good PBM partner who is willing to facilitate your pharmacy claim system programming. Clear communications for members and providers are also helpful.”
HealthPartners, and its marketplace, adopted the concept of using an exclusive specialty pharmacy over 10 years ago, said Strahl. “We felt this was the prudent step given the cost of the medications and the need for additional management for these high cost drugs.”
Strahl said payers should ask themselves the following when creating a specialty pharmacy network:
1. Should we build a specialty pharmacy or dispense them through existing pharmacies?
2. Do we think there is value in and is there a will to restrict dispensing to one or just a handful of pharmacies?
3. How do we ensure access to limited distribution drugs that network pharmacy partners can’t dispense?