The specialty pharmacy divide: How health systems and payers can find common ground

By integrating clinical pharmacists into care teams, specialty pharmacies within health systems can improve adherence and outcomes for patients with complex and chronic conditions, helping to prevent adverse events and lower the overall cost-of-care. But as annual premiums rise and the use of specialty medications increase, the full potential of health system specialty pharmacies can only be unlocked if health systems and payers work together.

During a June 30 webinar, hosted by Becker's Hospital Review and sponsored by Trellis Rx, two thought leaders shared the findings of a market research study on the dynamics between health systems and health plans when it comes to specialty pharmacy programs. The webinar presenters were:

• Andy Pulvermacher, PharmD, principal consultant at Blue Fin Group
• Jerry Buller, DPh, MMHC, chief pharmacy officer at Trellis Rx

Trellis Rx commissioned the study to find out why health systems and payers struggle to collaborate in the specialty pharmacy space and how those barriers can be overcome. It engaged a third-party company to conduct 20 in-depth, blinded interviews among leaders at health systems and payer organizations. In addition, Trellis Rx conducted interviews with subject matter experts from across the specialty pharmacy arena.

Here is what the research shows:

1. From a payer perspective. The main challenge related to specialty pharmacy facing payers is rising drug cost, which is exacerbated by The increasing use of expensive specialty and orphan drugs. They are also facing pressure to balance care costs from employees and employers on their plans, said Dr. Buller. The premiums keep rising, which angers their customers.

Also, payers' perceptions of health system specialty pharmacy have an adverse effect on their willingness to collaborate. They see specialty pharmacy services at health systems primarily through lens of dispensing, that is, getting the right medications into the hand of the correct patients, rather than as a specialized set of services. They also believe health system specialty pharmacies are more expensive than alternatives. Ultimately, payers see "health system specialty pharmacies as expensive providers of a commodity service," said Dr. Buller.

2. From a health system perspective. Health systems see specialty pharmacy as a strategic opportunity to improve care and outcomes for their patients, especially as they enter more risk-based contracts with payers. However, when it comes to establishing a specialty pharmacy service, they often face challenges related to accreditation, regulatory changes, and access to limited distribution drugs and payer specialty pharmacy networks, Dr. Buller said.

Health systems see payers as being driven solely by the bottom line, willing to sacrifice care quality for cost. While cost is a primary decision-maker for payers, providers don't always acknowledge the extent to which employers and patients pressure payers to keep costs in check.

Health systems also characterize their relationship with payers as "adversarial" and "hostile," which underscores a need for both stakeholders to step back and recognize that at the center of their relationship is the patient, said Dr. Pulvermacher. Both entities must keep the patient in mind during their conversations about specialty pharmacy services.

3. The common ground. The research did reveal a common goal that can unify both stakeholders, namely providing optimal patient care at a reasonable cost and enhancing the value of specialty medications for patients and their own organizations. There are also several beliefs that both stakeholders share, including that the increase in drug costs is unsustainable and that partnership can't be achieved via a cookie cutter approach — each partnership must address the unique needs of the two organizations.

"We would be remiss if we didn't say we can find common ground," said Dr. Pulvermacher. "And when you look at the trajectory of healthcare costs and premiums, we can't say that there is no opportunity to find benefits for all parties involved."

Learn more about Trellis Rx here, and view the webinar here.




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