New model for managing specialty pharmacy aims to improve quality at a reduced cost

April 27, 2015

Both public and private purchasers are in an important position to act as catalysts of change in managing specialty pharmacy.

Both public and private purchasers are in an important position to act as catalysts of change in managing specialty pharmacy, according to Jeremy Nobel, M.D., medical director of the Northeast Business Group on Health, New York, NY. 

“Purchasers, payers, and providers need to work together to develop value-based care delivery models with clear outcome metrics that can be used to develop a value-oriented market place for healthcare services,” Nobel told attendees of a session entitled Managing Specialty Pharmacy: We Can Do This! at the Academy of Managed Care Pharmacy (AMCP) meeting.

Nobel and his co-presenter Linda Bosserman, M.D, clinical professor, City of Hope Foundation, Duarte, California, highlighted the need for new models of healthcare delivery to counter the increasing cumulative costs of healthcare that are threatening affordability without adding value to quality of care. He cited data showing that only 55% of patients receive care in accordance with best practices, leaving 45% of patients who do not receive care based on best practices.

Into this environment, a value-based purchasing framework emerging over the past number of years based on prevention is aimed at providing high quality, low cost health care to a healthier population. Key evolutionary steps that are helping to achieve this include improved transparency of comparative performance of physicians, hospitals, and treatments, along with incentives and rewards that increase the market sensitivity to the quality and cost of physicians and hospitals. Also involved is the use of information technology and innovation by physicians, hospitals, and suppliers for re-engineering clinical operations.

Within this context, Nobel focused on the influence of value-based purchasing for specialty pharmacy and emphasized that managing specialty drugs requires effectively managing specialty care.

According to Nobel, managing the cost and value of specialty pharmacy will move from managing the drug piece alone to managing the whole patient.  He emphasized that this requires care that is evidence-based and data driven, as well as care that is driven within a person-centered care model that embraces and respects individual patient needs and eliminates unwarranted variation. Integral to this approach is supporting the patient in all areas of public health: medical (e.g., type of care needed, side effects of treatment), economic (e.g., costs/benefits of different treatment options, insurance coverage), and personal (e.g., will daily activities be affected by treatment?).

Essential to this whole person approach is the use of value-based payment with tools such as bundling, capitation, and pay-for-performance, and with a focus on total cost of care. “Accelerating specialty pharmacy pricing across a broad range of conditions mandates a bigger picture view than just managing increments of healthcare spending,” he emphasized.