The Value Proposition of Specialty Care

July 20, 2017| CATEGORIES: Specialty Pharmacy , Press Feature

Rebecca Shanahan, JD, the CEO of Avella Specialty Pharmacy, in Phoenix, suggested that the dramatic change in hepatitis C virus (HCV)—from a life-threatening disease to a curable one—illustrates well the evolution of specialty pharmacy.

“Historically, you had a disease that, left untreated, resulted in a requirement for dialysis, for organ transplant and sometimes evolved into cancer—none of which are curable diseases,” said Ms. Shanahan, who was asked to comment on the practice trends raised during the MHA Business Summit. “In the past three or four years, we’ve had these really wonderful oral [HCV] therapies that don’t create the side effects that accompanied the older drugs, like nausea, vomiting and depression. Plus, now they can actually cure you within eight to 12 weeks, depending on the person. That’s an amazing turnaround.”

Specialty Shines in Adherence

More generally, for serious conditions with complex therapies, specialty pharmacy can help patients get on and stay on appropriate therapy. Whereas average compliance for most patients on an oral medication is about 50% (Mayo Clin Proc 2011;86[4]:304-314), the compliance rate in specialty exceeds 90% (Manag Care 2009;18[10]:17-18). “That is a clear demonstration of the value proposition of specialty pharmacy,” Ms. Shanahan said. “Patients get on therapy earlier, stay on therapy longer, take the right dose at the right time and achieve better outcomes. That’s particularly important because these therapies are so expensive.”

Critical in this effort is helping patients understand their specialty drugs, why it is necessary to take them as prescribed as well as any potential side effects or other associated risks.

Specialty pharmacy also ensures that good support systems are in place and persist, and that all key clinical stakeholders are brought into the care continuum. Indeed, “we really are the navigators for patients when they get diagnosed with these really terrible diseases, and we excel at bridging doctors, hospitals, payors and manufacturers in the process,” Ms. Shanahan said.

“It’s a great time to be in specialty and it’s a great time to be in pharmacy because of all the really impressive gains we are making in science and biochemistry. Amazing things are happening.”

Payment Pressures

Still, clinical advances alone are not enough to ensure success; Ms. Shanahan echoed Mr. Agostino’s point that specialty pharmacy providers need to be paid adequately for their high-touch patient care services. Unfortunately, “the reality is that the cost of these medications yields specialty pharmacy 4% to 12% gross margins. After the cost of the drugs, there is very little left to pay for our high-touch services,” she said. “And those numbers are compressing.”

Avella is seeking a variety of ways to improve its efficiency, optimize quality of care and drive down overall costs. Two examples are mobile applications that remind patients to take their drugs and automated pill bottles that broadcast when a patient takes those medications. All of these strategies help Avella track adherence and intervene at the right time.

Another valuable approach is a “split fill” prescription strategy. If a doctor writes a script for 30 days, Avella may initially give the patient only a 14-day supply to be sure the drug is effective and well tolerated. The pharmacy also finds and secures financial help for patients who can’t afford their medications through foundations and manufacturers, including patient assistance programs.

“It’s really important that these kinds of services and support for patients remain in place,” Ms. Shanahan said. “The manufacturers who have relied upon us to be navigators of the health care delivery system, in partnership with doctors, continue to be reimbursed. Traditionally, there was some margin in drug costs to allow for these services. But now, we’re to the point where high-touch services that we know deliver such a dramatic enhancement in patient outcomes are at risk because of [current] reimbursement models. It’s something we need to work continuously on to ensure health plans find appropriate reimbursement for high-performing specialty pharmacies that are helping patients cure their diseases.”

Ms. Shanahan also echoed Mr. Agostino’s call for a more rapid embrace of value-based care models. Such programs, she noted, can help ensure that patients have the best opportunity for therapeutic success and that specialty pharmacies that demonstrate superior performance in clinical outcomes and satisfaction receive compensation. “Unfortunately, that’s not what’s happening now,” Ms. Shanahan said. “If you’re best in class, you get paid the average. If you’re average, you get penalized.”


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