By Eric Sullivan, SVP, Inovalon.
Included amongst the segments of healthcare such as post-acute care that until recently had been mostly overlooked, specialty pharmacy now is in the spotlight as a key area of healthcare utilization and spend in the U.S. Critical, expensive and often life-sustaining medications for high complexity disease states, as well as care management programs that help patients through their healthcare journey, are at the core, driving nearly $175 billion in drug spend for the 2 percent to 3 percent of the U.S. population considered medically complex. Specialty pharmacy operations typically involve a cross-functional staff of insurance experts, patient care coordinators, nurses and pharmacists that interact with patients and stakeholders to ensure therapeutic success in a historically fragmented, manual process-driven model.
Challenges in specialty pharmacy operations
As with many aspects of the healthcare system, specialty pharmacy operations are fraught with many pragmatic, economic, and clinical care challenges.
Operational, pragmatic challenges include:
- Multiple fax and phone communications between prescriber and specialty pharmacy supporting referrals, prescriptions, authorizations and patient care coordination
- Challenging and fragmented patient engagement combining traditional phone-based communication with other methods such as texting with mixed results
- Overlapping prescriber and patient communications among health plan, pharmaceutical manufacturer patient service hubs, prescribers and specialty pharmacy
These process challenges are creating an economic strain for the pharmaceutical industry, the payer, the provider, and most importantly the patient – where insurance benefit and funding source determinations often create confusion between overall coverage and patient out-of-pocket costs. This is compounded by complex coordination of benefits, billing and payment processing of medical and pharmacy claims, as well as other sponsored funding sources. Increasing patient cost share can make specialty drugs unaffordable for many patients which impacts medication adherence and ultimately patient outcomes.
The resulting clinical challenges make it difficult for critical patient care information to be easily shared (e.g. labs, patient assessments, medication profiles, side-effects, etc.). Additionally, treatment objectives often overlap among specialty pharmacy channel providers, resulting in crossed communications and patient confusion. In the end, key success metrics (both economic and clinical) are not easily measured, and often not operationally and clinically aligned.
The power of data accessibility and real-time analytics
Compressed specialty pharmacy margins require significant technology investment to offset operating costs and increasing service expectations. Technological advances help to address several of these challenges and as a result drive improvement in patient care and satisfaction, lower operating costs and more informed clinical decision-making.
Several of these technological advances that are showing early evidence of changing the historical paradigm include:
- Interoperability with EHRs and other critical patient history data sources providing access to holistic views of patient medical records which can improve patient engagement, therapeutic interventions and reduce unnecessary procedures
- Sophisticated workflow software driven by data-informed electronic protocols to support overall multi-party process efficiencies
- Robust and timely analytics that provide comparative and predictive insights that influence optimal patient care at the lowest cost as well as provide more timely, accurate patient insights that drive patient success, including medication adherence
- Integrated patient engagement technologies that improve patient interactions when and how the patient wishes to engage
Impact across the continuum
The application of advanced capabilities in connectivity and analytics in the specialty pharmacy space creates a more efficient system and a better result for all involved. Successful implementation of these technologies accelerates patients onto the most appropriate therapy, optimizes patient treatment plans and improves the overall patient experience which support medication adherence goals. It can also help establish innovative and more productive relationships between health plans, employers, providers, specialty pharmacies, pharmaceutical manufacturers and patients.
Specific to advanced predictive analytical capabilities, these enable a more seamless experience for patients who are attempting to manage often numerous chronic illnesses. In practice, this means ensuring that these patients don’t have to answer the same question multiple times or explain non-clinical elements of their care when filling an order. Technology that can identify and evaluate a patient’s needs amongst multiple medical conditions and extensive polypharmacy challenges is paramount. Most importantly, real-time analytics allow for improved clinical decision-making and individualized care for these complex patients.
With connections to the EHR and access to payer claim data, it also means providers who care for these patients experience easier prior authorizations of medicines. Advanced data and reporting capabilities further expedite prior authorizations and billing for patients, and real-time, payer-driven interventions become possible. Advanced data visualization and reporting capabilities help monitor for appropriate care of patients with chronic and complex illnesses, supporting specialty pharmacist-directed interventions within existing workflows.
In the end, by gathering essential insights and tracking the patient journey through real-time data visualization, specialty pharmacies and other key stakeholders achieve greater speed-to-value.