How Health Systems Can Overcome Barriers to Gain Payor Access

Published 07/27/2020
by Jerry Buller

This article is part two of a series on identifying and overcoming obstacles to payor access and relationships featured in the 340B Report. Read part one of the series here.

In a recent market research study, Trellis Rx found that pharmacy leaders from health systems and health plans agree greater collaboration is needed to enhance the value of specialty medications for patients.

Yet, even as the challenges posed by specialty medications mount for their organizations, these stakeholder groups struggle to work together to develop mutually-beneficial solutions.

Why is this? Through blinded interviews with 20 pharmacy leaders from health systems and health plans and 10 industry thought-leaders, we identified three barriers that currently stand in the way of patient-centered partnerships:

  1. Health system and health plan pharmacy leaders view each other antagonistically
  2. Most health plans do not recognize the potential value health system pharmacies can deliver to their members, customers and organizations
  3. Health systems struggle to demonstrate the value of their specialty pharmacy services

Overcoming Barriers to Partnership: Strategies for Health Systems

In addition to uncovering barriers, our market research study revealed steps both stakeholder groups can take to promote greater collaboration and gain payor access. In this article, I highlight three strategies covered entities should leverage to establish specialty pharmacy partnerships with payors.

  1. Facilitate Meaningful Dialogue. The research found that many health plan pharmacy leaders have significant misunderstandings about the capabilities and goals of health system specialty pharmacies. Likewise, many health system pharmacy leaders said they don’t understand health plans’ challenges and goals.

    As one health system respondent explained: “I don’t understand their picture of the world. Many times, I’m surprised because they don’t understand what we’re doing on our side of the world. We don’t talk. Usually the patient is the ping-pong ball in all this.”

    Overcoming these misunderstandings to build patient-centered partnerships will require communication and education. Both stakeholder groups must set aside negative preconceptions in favor of listening and learning. As one industry thought leader shared: “The first thing that needs to happen is health systems need to have more meaningful conversations with the payors and look at it as more of a partnership than it is an adversarial role.”

    In my experience, partnering with your health system’s managed care team is the best way to begin facilitating meaningful dialogue. However, these colleagues may not have expertise in specialty pharmacy. As such, you should be prepared to provide them with information and support.

  1. Offer differentiated value to payors. To achieve this, health systems must first build a specialty pharmacy service that offers unique benefits to payors. This requires taking a strategic, system-wide approach and investing in the personnel and technology required to establish a clinically-integrated care model.

    Ultimately, the clinically-integrated care model is what sets health system specialty pharmacy services apart from other alternatives. Having direct access to patients and providers, as well as the EHR, allows health systems not only to promote a more coordinated experience, but also to better monitor the appropriateness and effectiveness of specialty medications. This translates into better outcomes and fewer adverse events like ED visits and hospitalizations.

    As one health plan respondent shared, health systems have “the advantage of looking at the big picture and making an integrated decision on pharmaceuticals.” Another explained that health system specialty pharmacies “have a much stronger influence over individual provider behaviors than do health plans by far.”

    To prove value to health plans, health systems must also move beyond collecting operational, volume-based measures to track disease-specific clinical outcomes metrics. Although not easy, using tools like the RAPID-3 assessment to track disease severity in patients with rheumatoid arthritis enables specialty pharmacy teams to ensure therapy effectiveness, improving care quality and costs.

  1. Be prepared to negotiate. Finally, health systems must be prepared to give and take. Often, health system specialty pharmacies must initially accept parity pricing, or better, to gain access.

    Health systems in risk-based contracts have leverage in contracting discussions. Because health systems are fully responsible for cost-of-care and outcomes in these contracts, they need full control of patients across the care continuum, including their medication journey.

    Pharmacy leaders should work with their health system’s managed care teams to understand how to approach negotiations but should work to begin educating payors about the benefits of their specialty pharmacy services well in advance of contracting conversations.

    Ultimately, by leveraging these strategies, covered entities can take steps towards establishing patient-centered specialty pharmacy partnerships that will benefit their patients and organization but also create value for payors.

Download the market research report on Trellis Rx’s website for additional insights building specialty pharmacy partnerships to gain payor access. If you have questions, please contact