Costs Associated With the Use of a Health System Specialty Pharmacy Health Care for Medicare Advantage Beneficiaries

Use of a health system specialty pharmacy (HSSP) may be associated with a lower health care cost, according to a retrospective cohort study that examined Medicare Advantage beneficiaries' medical and pharmacy claims from 2018 and 2019 (J Manag Care Spec Pharm. 2022;28(2):244-254; doi:10.18553/jmcp. 2022.28.2.244).

Although HSSPs are associated with better clinical outcomes such as improved medication access and adherence rates, data on the effect of these pharmacies on health care costs and utilization have been sparse. 

To provide additional data on this effect, researchers retrospectively studied the medical and pharmacy claims of a national sample of Medicare Advantage beneficiaries from 2018 and 2019. As a result, they found using a HSSP was associated with lower health care costs.

“Our study is the first to examine the cost-saving effects of HSSPs on a multihealth system scale,” wrote David McManus, MD, ScM, Department of Medicine and Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, and colleagues. 

“These findings corroborate previous evidence that HSSP use was associated with reduced provider burden and streamlined specialty medication management [as well as increased physician satisfaction] driven by lowering time to initiation of specialty drugs, a particularly important consideration in the care of these medically complex patients,” wrote Dr McManus and colleagues. 

The researchers obtained their sample of 9780 members from Optum Advisory Service’s Normative Health Information database, which includes claims, membership, and provider data for 12.6 million Medicare Advantage members. 

They assigned members who filled a prescription at a HSSP to the intervention group and assigned those who did not use a HSSP but had the same provider to the provider benchmark group, one of two comparison groups. The other comparison group, designated the network benchmark group, included members who had a different provider than the members who used a HSSP.

The study’s primary outcome measure was total health care costs/patient/month. The researchers used the Centers for Medicare & Medicaid Services Hierarchical Condition Categories risk-score method to calculate cost and utilization on a risk-adjusted basis. Then they assessed differences for categorical variables by using chi-square tests and differences for continuous variables by using two-tailed t tests.

During the 2018 baseline period, total health care costs and utilization after risk-score adjustment were similar among groups. These adjusted costs were $9520 for HSSP users, $8691 for the provider benchmark group, and $9510 for the network benchmark group. 

However, during the 2019 follow-up year, the costs for all groups were lower that for the baseline period. Moreover, the $7060 cost/patient/month among HSSP users (n=208/9780, or 2%) was lower than the $7683 cost/patient/month for the provider benchmark group (P=0.31) and significantly lower than the $8152 cost/patient/month for the network benchmark group (P=0.03).

“The differences in 2019 were primarily driven by savings in pharmacy and free-standing physician-related costs,” wrote Dr McManus and team. 

“As HSSPs become more widely available and used, the focus of research should shift to cost-effectiveness analysis and pseudo-randomized effectiveness study for specific disease states to inform health care practices and strategic decision making at an institutional level,” they concluded.