Strategies Health Systems With Integrated Specialty Pharmacy Use to Support Complex Patients

As the ongoing shift to value-based care inspires health care providers to maximize efficiency, health systems with an integrated specialty pharmacy have established a model that can address specific inefficiencies in treating complex patients. With a specialty pharmacy inside the walls of the same hospital where patients see their specialists and primary care physicians, those providers can improve the quality of care for specialty patients who require high-touch care and medications that can cost as much as six figures per year. 

The percentage of patients taking at least one specialty drug per year increased by 18% between 2017 and 2019 and to answer that demand, health systems with in-house specialty pharmacy rely on an integrated care model that supports continuity and quality of care. These are the strategies they have employed that have helped them increase patient access to specialty medications, encourage drug adherence and ultimately improve health outcomes for complex patients.   

Developing and Integrating the Specialty Care Model 

By integrating outpatient specialty drug therapies into existing care models, health systems can build a cohesive ecosystem between specialty clinics (oncology, infectious disease, cystic fibrosis for example) and the outpatient pharmacy that creates a simpler, streamlined workflow and improved patient experience.   

Health systems with integrated specialty pharmacies can also deploy pharmacy liaisons to maintain regular communication with patients and elevate medication issues or concerns to the physician. Having that support mechanism in place for the patient allows the physician to rapidly adjust therapies when needed. Clinical integration is a key differentiator for health system-owned specialty pharmacy compared to retail specialty pharmacy, where medication issues only become apparent when the patient returns for their next scheduled appointment or a dire issue arises.

A Clearer View of Patient Populations

Some health systems with integrated specialty pharmacy across the country share aggregated data from specialty patient populations that include rare and complicated diseases. Those health systems, drug manufacturers and payors can leverage those data for real-world insights into population health, disease-state specific patient outcomes, medication adherence rates, drug and treatment performance, and much more.    

The scope of those health systems’ services and scale of their patient populations allow them to benchmark patient outcomes against each other and to collaborate on best practices.  

Combat Drug Access Inequities  

When specialty pharmacy services are owned by the health system and based on an integrated care model, it gives patients access to local resources that can help overcome barriers to care. Medical bills are the leading cause of bankruptcy and financial insecurity in the US and specialty patients on extremely expensive medications are vulnerable to financial stress.  

Health systems are uniquely qualified to combat financial barriers to care because they treat all patients regardless of ability to pay. Health systems also reinvest in community care through programs such as the 340B drug pricing program, which gives hospitals discounts on certain drugs for eligible patients. The health system infrastructure and local footprint also have mechanisms to connect patients to community resources—such as financial aid—and provide access to preventive care and other programs. 

Capturing and Retaining Patients

Health system-owned specialty pharmacies compete with Fortune 50 pharmacies including CVS, ExpressScripts, and United Healthcare for patients—all companies with vast resources to engage with patients. In addition to the competitive landscape, less than 5% of all patient visits result in a qualified script for the specialty pharmacy and many visits do not result in a new script. Even if the visit does result in a specialty script, it may not qualify to get filled because of restrictions from insurers or drug manufacturers.  

While those factors make it challenging to capture and retain patients, the health system-based specialty pharmacy has several key advantages: white-glove customer service that includes administrative and financial support, and an unmatched level of patient care built on coordination between the patient’s full care team. 

Managing Compliance and Administrative Requirements 

Finally, health systems are equipped to navigate convoluted compliance and administrative responsibilities that are unique to specialty pharmacy and require significant resources. For instance, if the specialty pharmacy participates in the 340B pricing program, the Health Resources and Services Administration (HRSA) and individual drug manufacturers can audit hospitals to check for compliance, making it essential for them to manage the 340B program with the highest level of scrutiny and avoid repaying previously captured discounts.

In addition to compliance standards, health system-owned specialty pharmacies maintain the highest levels of accreditation. The industry has long considered URAC accreditation the gold standard, but as more pharmacies enter the marketplace, the health system-owned specialty pharmacies increasingly achieve dual accreditation status from the Accreditation Commission for Health Care (ACHC) in addition to URAC. Health system-owned specialty pharmacies further augment these already high accreditation standards with the additional requirements necessary to participate in the restricted specialty networks of PBMs and payers, which represent nearly half of the total market opportunity. 

Health systems with integrated specialty pharmacies can completely transform clinical care for the most vulnerable patients by providing superior treatment. By uniting all aspects of the patient’s clinical care in an integrated and coordinated model, the health system builds a supporting environment around the patient that can mitigate the risks of a patient missing doses of their medication or missing an appointment.

As health systems take on more financial risk in a value-based health care system, it is essential that they manage medication adherence to the highest level. Otherwise, patients may risk hospital readmissions or faster progression of their condition. None of the hurdles listed above are insurmountable, but they do require significant expertise and health systems with integrated specialty pharmacies are uniquely positioned to handle them.

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