In the era of COVID-19, providers, payers, and other organizations critical to providing effective and cost-efficient care have realized the value in partnering with one another to solve unprecedented industry challenges. But as noted by Andy Pulvermacher, principal consultant at Blue Fin Group, in a recently released report on health system and payer alignment, “Why did it take a pandemic to rally around collaboration? Why aren’t we always working together to solve the problems that threaten our healthcare system and patient outcomes?”
Pulvermacher further stated that specialty pharmacy—which focuses on high-cost, high-touch medication therapy for patients with complex disease states—"serves as a flashpoint of these challenges and represents one of the greatest opportunities and challenges facing the healthcare industry today.” He wrote, “When appropriately managed, specialty therapies have immense potential to improve clinical outcomes and quality of life. These improved outcomes should reduce the total cost of care through lower healthcare utilization, yet we fail to recognize these benefits because we struggle to define the meaningful clinical endpoints to specialty therapies.”
The report, produced by Trellis Rx, a technology-enabled specialty pharmacy services provider, offers new insights into why health system specialty pharmacies often struggle to partner with payers. The study found that misperceptions about health system specialty pharmacies’ capabilities, outcomes and pricing often pigeonhole them into being seen as expensive providers of a “commodity” services by payers.
To discuss these issues further—as well as the steps they’ve taken to shift operations in response to COVID-19—Healthcare Innovation recently spoke with John Feucht, vice president, pharmacy services at Summa Health, an integrated healthcare delivery system in Northeast Ohio, and Stuart Deal, the manager of Summa Health's specialty pharmacy. Below are excerpts of that discussion.
Can you provide some background on the alignment between specialty pharmacies and payers? What steps can both sides take to have greater collaboration?
Feucht: From the health system perspective, we want to make sure that when we are talking about specialty medications, we're able to ensure that our patients are adherent and compliant with their medication regimen. We know these medications are high-cost, both for health plans and out-of-pocket for patients. We want to do everything possible to make sure that we are able to keep that patient on his or her therapy.
As we move more towards value-based purchasing and some of the other dynamics that we're seeing in healthcare today, more medications are moving to the ‘specialties’ tier, based on their costs and the unique biotechnology that’s behind some of these therapies. A wise pharmacist told me at one point in time that the most expensive therapy that you ever put a patient on is the one that doesn't work. So, we need to do everything we can to leverage the resources and expertise of pharmacists and pharmacy technicians in providing care in a high-touch manner to our patients to ensure that they have access to those medications, and that we are attacking any type of barriers that [stand in the way] of them staying on therapy.
When we collaborate with our physicians in provider offices, we want to make sure that we have a model in place that we can deliver that high-touch care. And we're able to do that by internalizing our own specialty pharmacy. So we have the specialty pharmacies on-site that can handle both the dispensing and the high-touch clinical aspects with either face-to-face or telehealth interventions.
From a specialty pharmacy perspective, what were operations like pre-COVID and in which ways have things changed in the past six months?
Feucht: Pre-COVID, [our model] was a health system-based specialty pharmacy where we had pharmacists and pharmacy liaisons embedded within the clinics. So they're working at the elbow of the provider, seeing and managing these patients. It’s really part of the patient visit: handling tasks such as prior authorizations, and identifying events or any barriers we have to adherence and compliance. When you look at the shift to the COVID [era], we were well positioned to move that into a virtual environment without any missteps.
Deal: While we had implemented an embedded model—where the patient is meeting with physicians and pharmacists in the clinic—there's still a great deal of interaction that happens on an ongoing basis, based off their dispensing patterns, that are telephonic, and there's still just as much value in that high-touch models telephonically as there is in person.
Ideally, we try and create that first face-to face-visit. Beyond that, obviously the patient isn't coming in every full cycle for an appointment; however we're following up proactively five to seven days before their medications are due, and we’re able to build that patient-pharmacist or patient-liaison relationship already via telephonic messaging [through things such as] coordinating their bills, making sure everything's sent out, and even doing critical assessments with our pharmacists.
Ultimately, with the switch to a more remote type of work, we were already well positioned to still provide that same level of care and same clinical expertise, just in a slightly different manner. We already had the mechanisms in place that allowed us to have an effective telephonic interaction and patient-engaging experience beyond just the in-clinic piece. Ultimately, it's a direct care team, so when that patient calls or sees them in person, they know it's Megan my pharmacist, for example.
How has the feedback been from the patient’s perspective?
Deal: One of the big elements is the relationship they've created with the care team member. We have found that patients who are already in a fragile disease state can become very unnerved and don’t necessarily know what to trust. There was a lot of information going around, and it was tough to know exactly who to trust and what to trust. They had concerns about showing up to clinics and sometimes there would be appointments that they absolutely couldn't miss. So our team became almost a calming force for them; a resource they can lean on and depend on to provide the appropriate information.
Can you broadly discuss how the pandemic has changed the specialty pharmacy sector, and how does the future look like to you?
COVID-19 created or augmented some challenges that we see in the space, including medication access and affordability. For Summa, our model was well prepared to shift to that telephonic approach to ensure continuity of care. We wouldn't be able to do that without our partnership that we have with Trellis [and their platform that integrates into the EHR to support patient identification, day-to-day operations, clinical management, and data analytics and reporting].
We have patient-reported outcomes that [show] the effectiveness of our program. For our proportion of days covered (PDC) [the total number of days covered by refills in a measurement period divided by the number of days between the first fill and the end of the measurement period], which is a big metric in the specialty space, year-to-date in 2020 is an average of 91. Our average copay is $12.81. Our turnaround time is 1.86 days. Through our model, we've actually been able to demonstrate consistency, and in some cases improvement over what we saw pre-pandemic.
How will you continue to measure progress in this area?
Deal: We now have real-time disease-state dashboards that allow our team to actively manage all the clinical goals that we have. We [want to] continue to evolve the clinical metrics specific to each disease state, ultimately looking at a number of different elements related to patient-reported outcomes. It’s not just about looking at adherence and PDC scores, but taking that one step further to go above and beyond to say, yes we build and ship this every month on time and have 100 percent ‘adherence,’ while also looking at how we can measure that it's actually effective for the patient.
Feucht: And looking at the anecdotal part, with our cancer center, for example, it’s a great testament of an area where patients were very accustomed to face-to-face visits with the pharmacist and liaison, and our providers were used to seeing the pharmacy team there on a daily basis. We were able to pivot those folks to a remote setting, and still engage patients telephonically without missing a beat. So the providers are able to reach out to the pharmacist; it is only by phone now rather than seeing them face-to-face. Once we demonstrated that the models are working, providers and patients gained confidence. We realized that as we move forward and if we expand operations in other clinics, we already have the infrastructure in place to support both face-to-face and remote interactions.
