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Emergence of Specialty Pharmacy in Integrated Systems – a Patient-Centered Model with Significant Potential that Manufacturers Need to Understand and Support

“Integrated systems” like Carolinas HealthCare System, Fairview Health Services and Vanderbilt University Medical Center are developing powerful integrated pharmacy models for key specialty disease states.  These emerging models have incredible potential because they embed and integrate pharmacy into the overall clinical care for a patient, which is impossible today in the traditional specialty models that consist of a manufacturer-sponsored patient support HUB and a network of mail order specialty pharmacy providers which are isolated from the patient’s clinical care.  Though this emerging integrated system specialty pharmacy model is obviously superior (see Figure 1), it is still very early in its development.  For it to grow and mature it requires two things to change:

  1. Manufacturers need to figure out how to engage and collaborate with these new specialty pharmacy models, while at the same time continuing to work with their traditional patient support HUB and mail order specialty pharmacy provider models
  2. The integrated systems need to execute a variety of strategies to increase the number of patients that can be fully managed within their models

April Post 2015 JB

Integrated Pharmacy System model for specialty diseases

Over the past 5-10 years leading manufacturers have become skilled at creating appropriate physician and patient support programs and distribution / dispensing channel models for specialty products.  Today, the hallmark of a commercially successful specialty product is a high-quality, seamless and consistent physician and patient experience throughout the patient and treatment journeys.   But, no matter how elegant and well-executed a specialty product’s support programs and channel strategies may be, they are not integrated with the patient’s clinical care at their local site of care.  The fundamental constraint for typical specialty product models is that the pharmacy cannot be tightly and effectively integrated with patients’ clinical care in the local setting.  The potential game changer is that new specialty pharmacy models emerging from top integrated systems eliminate this constraint!  Herein lies the challenge for manufacturers.

The integrated system specialty pharmacy models will never be able to reach their potential if they cannot get access to manufacturers’ specialty products.  Manufacturers need to approach the integrated system specialty pharmacy models differently:

  • The typical manufacturer approach of offering various physician and patient support programs administered by a third-party HUB and a network of specialty pharmacy providers and specialty distributors based on their ability to service the physicians and patients is not relevant. An integrated system pharmacy model usually consists of its own support program HUB, a diverse set of pharmacy assets, internal purchasing and distribution capabilities, and most importantly, frequent collaboration and interactions between the providers of a patient’s clinical care and the providers of a patient’s pharmacy care.
  • The typical manufacturer approach of reusing a legacy list of specialty pharmacy provider data elements would only scratch the surface of the potentially valuable information that can be captured by an integrated system pharmacy. An integrated system pharmacy model has access to powerful and unprecedented data because the pharmacy and hub personnel also work within the integrated system’s electronic medical records, the scheduling system, and the coding and billing system.  A manufacturer can access clinical care and outcomes data that enables refined and realistic value proposition messaging back to regulators, payers and gatekeepers.

Not only do manufacturers need to work differently with the integrated system specialty pharmacy model, but they will also need to keep one foot in the old world of existing physician and patient support program and distribution/dispensing channel models. If the new model continues to grow, it will take time as each “integrated system” figures out the specific model that best meets the needs of its patients and health care providers and then maximizes the scope of patients managed within it.  For the foreseeable future, manufacturers that choose to capitalize on the integrated system specialty pharmacy opportunity will need to keep one foot in the old world and one foot in the new world.

The onus to support the emergence of integrated system pharmacy models is not just on manufacturers – the integrated systems also need to make some changes.  The leadership of the integrated system pharmacy organizations need to get aggressive with expanding the scope of patients that are fully managed within their superior settings.  This will not be an easy road, and it needs to consider a multifaceted strategy to increase “market access”:

  • Patients that are integrated system employees
  • Patients that are served by integrated system insurance plans and products
  • Patients of locally and regionally relevant payers
  • Potential patients captured due to the integrated system’s therapeutic area focus and excellence
  • Potential patients from the integrated system’s extended affiliates

Many of the integrated system specialty pharmacy models already serve patients from the first two bullets: their own employees and patients of their insurance products.  Today, it’s an integrated system’s major payers that are its main barriers to growth.  Though insurers and pharmacy benefit managers (PBM) agree with the clinical benefits of the new model, their current network decision criteria are exclusively financial.  The payers and PBM’s come to the table with reimbursements that are often shocking for the integrated system pharmacy teams.  The integrated system specialty pharmacies’ leadership need to look at the big picture and consider the financial benefit of broader access to more manufacturers’ products as their market access increases through more payer contracts.  The leadership of the integrated system pharmacies will need to learn to “hustle” for market access similar to how independent specialty pharmacy providers have been growing their businesses the past five years, by fully exploiting their unique niches.

Even though the integrated system specialty pharmacy model is a clear victory for patients, physicians, payers and manufacturers, we are faced with a classic chicken-and-egg problem.  Manufacturers want to see more patients within these new specialty pharmacy models before they take them seriously.  The integrated system specialty pharmacy models need access to manufacturer products in order to provide holistic pharmacy care to their patients, to be fully integrated in the patient’s local clinical care, to prove their models and to support growth.   Our intention for this post is to raise awareness to the opportunity and the challenges for both sides.  Expect to hear more from us on this topic in the future!

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