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Is Your SP Ready to Stand Behind Performance Guarantees?

We recently sent an Alert on the future of specialty pharmacy and much of that piece focused on value-based therapy management. In a value-based deal the manufacturer is making a promise that its product will meet predetermined criteria and, if not, will compensate the payer for failing to do so. We spoke to the role that specialty pharmacies can play in expediting such deals as SPs are closest to the patient and are adept at capturing complex patient-specific data.

The article below is written for health system owned SPs….. but the message applies across the industry….. now putting the specialty pharmacy itself in the hot seat to meet predetermined performance criteria. Having to meet guarantees should get SPs concerned. Unlike the performance of a drug in the patient population, the number of service variables that could impact an SP performance program are enormous.

Payers have been asking for performance guarantees well over a decade and guarantees are often the subject of extended negotiation when a payer is contracting a new SP. Ultimately, the set of guarantees must be easily measured as we saw in the manufacturer programs. Payers are pushing for more as they know SPs have enhanced their data capture / patient tracking capabilities. We see the guarantees including new categories as well as larger penalties. It would not surprise us to even see SPs included in a manufacturer’s value-based performance program one day soon.


Health-System Specialty Pharmacies: Lots of Data, but What Do Payers Want to Know?

Although health-system specialty pharmacies have access to an abundance of clinical and dispensing data, according to one expert who spoke during a session at the 2020 NASP Annual Meeting & Expo Virtual Experience, some pharmacies in outcomes-based contracts continue to ask payers the same question: What outcomes do they want to know about?

That’s the “million-dollar question,” said speaker Bryan Schuessler, PharmD, MS, the director of home infusion and specialty pharmacy at Saint Luke’s Health System in Kansas City, Mo. “What is it that people really want to see on that payor line? We’re not sure from payor to payor what’s valuable at this point.”

Many other health-system specialty pharmacies that are drawing up outcomes-based contracts are likely in the same boat, finding that payors do not always know what outcomes they want to have measured as part of a contract, Dr. Schuessler said. “Is a clinical outcome SVR [sustained virologic response] or is it days-to-therapy, or is it adherence?” he asked.

Dr. Schuessler noted that his team draws on a large pool of data from the Saint Luke’s electronic medical record system as well as dispensing and clinical documentation data from their retail and specialty pharmacies. “We’re documenting all these things. We’re following patients. We’re making notes. We’re collecting all this data, but … we’re still struggling to understand what [payors] want to see,” he said.

At West Virginia University Hospitals, in Morgantown, a lack of payor clarity on the question of outcomes has led Louis Sokos, BS Pharm, MBA, the director of allied health solutions, specialty pharmacy services, to formulate what he believes is a universally applicable equation. Specifically, he said, demonstrating the impact of specialty pharmacies on both clinical outcomes and total cost of care for the health system is “a value proposition that I think any payor can see.”

He stressed that health-system specialty providers have “to make sure we manage our patients as efficiently as we can and drive down costs overall … to make sure we’re a player in this space.” For example, his specialty pharmacy looked at a group of the health system’s patients receiving antiviral medications and documented SVR rates that were higher than those of most nearby pharmacies outside their system, showing “a better return on investment” for payors, he said.

Other health-system specialty pharmacies should take similar initiative and articulate what they believe to be the value of their services, suggested session moderator Erin Hendrick, the senior vice president of hospital strategy at Shields Health Solutions, headquartered in Stoughton, Mass. “We seem to have, as a collective, been very reactive to the data that’s been requested of us,” she said. Instead, Ms. Hendrick said, “I think there’s an opportunity for health systems to better define what we believe good specialty outcomes really are.”

By David Wild
Specialty Pharmacy Continuum


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