Offer integrated specialty pharmacy care ⁠to your patients

An article in the October 2019 edition of RADAR on Specialty Pharmacy published by AIS Health highlighted North Memorial Health’s successful specialty pharmacy program partnership with Trellis Rx. Read the full article below. 

In-House Specialty Capabilities Can Benefit Health Systems

By Angela Maas of AIS Health

As the specialty pharmacy space continues to grow, more entities within the health care system are boosting their capabilities in this area. Various health systems are implementing some form of a specialty pharmacy, often coordinating this effort through various partnerships. One such example of this is North Memorial Health and Trellis Rx, which began working together in 2018. The two companies spoke with AIS Health about the experience and the outcomes the collaboration has produced.

The Minnesota-based North Memorial Health system includes two hospitals, 26 specialty and primary care clinics, urgent and emergency care offerings and medical transportation services, and has more than 350 care providers and more than 6,000 team members. Trellis Rx, which started in 2016, partners with health systems in order to finance, build and operate specialty pharmacies.

The health system began offering specialty pharmacy services in 2009 though North Memorial Health Cancer Center. A patient advocate was placed in the clinic with a goal of providing support, including financial assistance, to patients requiring intravenous chemotherapy. That focus eventually expanded to include oral oncolytics, explains Paul Krogh, Pharm.D., system director of pharmacy services and infectious diseases at North Memorial Health.

Another person was added in 2015 to help support customers on additional specialty drugs. This expansion, he says, was because “many of our customers struggled to afford these therapies, and our providers spent numerous hours on prior authorizations and other required paperwork. Adding another financial advocate allowed us to provide comprehensive support to patients prescribed IV and oral oncolytics.”

Other specialists began asking for similar support, Krogh tells AIS Health, but “unfortunately, we didn’t have the capacity to extend services to other customers at the time.”

That same year, the health system began serving its employees taking specialty drugs through its retail pharmacies. “We became the preferred specialty pharmacy for our employees in May and captured 72% of these prescriptions within just six months,” he says.

Prior to the partnership, North Memorial Health served its cancer patients and employees via three on-site retail pharmacies, supplementing them with 340B contract pharmacies for limited-distribution drugs.

In November 2018, North Memorial Health unveiled its partnership with Trellis Rx. Initially available within the oncology and infectious disease spaces, the model expanded the existing offering to include “direct, in-clinic access to pharmacists and patient liaisons” to help with the coordination, education and support of people on specialty drugs. It also helps acquire insurance authorization and locate financial assistance.

Trellis Rx provided an experienced team to work in North Memorial Health clinics, including a program manager who oversees day-to-day operations. It also integrated a specialty pharmacy technology solution with the health system’s electronic health record system and “implement[ed] customized strategies to gain access to payer networks and limited-distribution drugs,” says Krogh, which previously had been “a major challenge.” Trellis Rx, he says, helped the system quickly gain access to five limited-distribution drugs. “Their support was also pivotal to us gaining access to Blue Cross Blue Shield of Minnesota this fall.” In addition, Krogh states, Trellis Rx shifted “all financial and operational risk away from us: They offer a 100% performance-based business model that aligns their incentives to ours and greatly reduces our related operating expenses.”

Model Has Expanded Since Its Start

“Partnering with Trellis Rx has allowed us to rapidly extend high-touch, personalized specialty pharmacy services to more customers who require these therapies to manage chronic and complex conditions,” says Krogh. Since its start, the model has expanded to four clinics and added six on-site specialty pharmacy team members. “In our first 10 months, we supported over 600 patients and grew specialty pharmacy revenue by almost 100%,” he says. “Most importantly, we have addressed many barriers to medication access and adherence. As of August, we have connected patients with over $600,000 of financial assistance and reduced turnaround time from around 14 days to just 1.9 days.”

Other outcomes based on data from November 2018 through August 2019 include:

• 98% average adherence based on proportion of days covered.
• 100% hepatitis C treatment completion rate.
• 127% improvement in the Net Promoter Score, which measures people’s willingness to recommend a company’s services, from -62 to +65.

“We attribute these results to Trellis Rx’s fully integrated model,” says Krogh. Critical to the health system’s success, he contends, are the on-site program manager, pharmacists and pharmacy liaisons and Trellis Rx‘s Arbor technology.

In fact, North Memorial Health is “exploring options to launch a pharmacy specifically for specialty pharmacy and employee mail order within the next two to three years,” Krogh tells AIS Health.

In the management of people taking specialty therapies, pharmacists “are increasingly being recognized as critical care team members — something we’ve always believed,” says Tony Zappa, chief solutions officer at Trellis Rx. With the high costs and adherence issues among specialty drugs, “clinic-based pharmacists add value by helping providers select the most appropriate specialty medications for patients and then monitoring the clinical impact of these therapies over time. If a specialty medication isn’t having the desired clinical impact, pharmacists can flag this for providers sooner and recommend alternative therapies. Pharmacy liaisons also help address the financial toxicity that prevents many patients from accessing these therapies.”

Zappa points out that health systems offering clinic-based specialty pharmacy services is a trend that continues to grow. “This model was primarily used by academic institutions at first, but now we’re seeing community and rural health system like North Memorial Health successfully adopt it too,” he says, adding that multiple trends are driving the adoption of the model.

First, “vertical integration of health plans, PBMs, and retail providers…is forcing health systems to differentiate their outpatient clinics to compete with retail providers,” says Zappa. “It’s also driving health systems, especially those in at-risk and value-based contracts, to find innovative ways to partner with health plans.”

As reimbursement for specialty drugs shifts from buy and bill within the medical benefit to the pharmacy benefit, health systems can provide more comprehensive patient care if they can fill and administer not only medical benefit drugs but also those adjudicated under the pharmacy benefit, he points out. Having a holistic view of a person’s care “means providers have visibility into whether or not patients are picking up and refilling prescriptions — information that can be difficult to track down when working with an external pharmacy.” In addition, being able to provide therapies regardless of their benefit gives the health system a “financial advantage.”

Comprehensive View Means Better Care

Having the ability to access integrated pharmacy and medical records allows for a comprehensive approach to health care. By having its own specialty pharmacy, North Memorial Health is “able to offer the highest level of care to customers,” asserts Krogh, adding that patients’ experiences with external specialty pharmacies often are “confusing and uncoordinated.” According to Zappa, “as ‘consumerization’ increases in the health care industry, health systems must differentiate themselves by providing a convenient, data-driven and personalized experience to attract and retain patients.”

Zappa explains that “providers often spend up to two hours per day managing administrative tasks required for specialty medication prescriptions, adding to the current burnout epidemic.” With specialty liaisons handing administrative work, an internal specialty pharmacy can “reduce the burden of specialty medications on our providers, which boosts their satisfaction,” says Krogh.

Finally, Zappa tells AIS Health, “as health systems invest in outpatient services to combat inpatient revenue declines and improve margins, offering on-site specialty pharmacy services can bolster this strategy. In addition to creating a multi million-dollar revenue stream, a specialty pharmacy program can improve a health system’s bottom line by attracting more patients to its outpatient clinics and reducing the total cost of care.”

Systems Should Consider Various Issues

Asked what advice he would give to a health system considering implementing a specialty pharmacy, Krogh replies, “consider what kind of support you will need to be successful. Are you looking for a consultant, or are you looking for a partner that will fully implement a specialty pharmacy for you? Ensure you understand the different options and the amount of resources needed for each option. Choosing the appropriate partner is the most important step to ensure you meet the needs of your customers and your business. Leverage at-risk share and accountable care contracts. Keeping more of a patient’s care in-house through expanded specialty pharmacy offerings aligns with and helps supports care models being built to support customers covered on these at-risk plans. “

According to Zappa, “a specialty pharmacy initiative must be an enterprise effort, not a pharmacy program. As a result, health systems need both organizational capabilities as well as pharmacy-specific ones to succeed. A lack of necessary pharmacy-specific and organizational competencies can delay or, worse, inhibit a program’s success. It may also cause health systems to miss opportunities to enhance clinical outcomes and improve patients’ experiences with their brands.”

Contact Trellis Rx to discuss how a specialty pharmacy program partnership can accelerate development or expansion of your in-house specialty pharmacy.

Oral oncology medications have become more common in recent years with half of cancer drugs approved in 2017 being oral oncolytics. As a result, physicians now prescribe oral cancer medications to many patients with advanced solid tissue tumors in addition to or instead of intravenous chemotherapy.¹

While oral oncology medications have many benefits, they have also created new challenges for patients and their providers. Enabling patients to access and start these therapies in a timely manner remains a significant issue. Affordability, prior authorization, and other factors often delay initiation of therapy, leading to turnaround times* of two to three weeks.²

In addition to causing anxiety and stress for patients and their families, delays in therapy initiation have been associated with increased mortality for certain cancers, especially in their early stages. Thus, addressing these challenges has the potential to both improve the patient experience and enhance clinical outcomes.

Clinic-based health system specialty pharmacies significantly reduce turnaround times compared to external specialty pharmacies

Recently, three of our health system partners compared the average turnaround times of oral oncology medications dispensed by their clinic-based specialty pharmacies to the average turnaround times of oral oncology medications dispensed by external specialty pharmacies.

To obtain turnaround times from external specialty pharmacies, the health system specialty pharmacies contacted independent and PBM-owned specialty pharmacies that filled oral oncology medications from a health system prescriber.

Each health system found that the average turnaround time for patients using their clinic-based specialty pharmacy was significantly shorter than the average turnaround times for patients using external specialty pharmacies:

• Health System A**
  • Health system specialty pharmacy: 2.5 day average turnaround time
  • External specialty pharmacies: 23 day average turnaround time

• Health System B
  • Health system specialty pharmacy: 2.4 day average turnaround time
  • External specialty pharmacies: 14 day average turnaround time

• Health System C
  • Health system specialty pharmacy: 1.3 day average turnaround time
  • External specialty pharmacies: 9.7 day average turnaround time

Health system specialty pharmacies address barriers to specialty medication accessibility, enabling patients to start therapy sooner

When specialty pharmacy services are integrated into outpatient clinics, health systems can provide the high-touch, personalized care patients prescribed specialty medications require. Compared to external specialty pharmacies with remote or reactive patient engagement, health system are uniquely positioned to reduce turnaround times by proactively addressing barriers that delay patients from starting therapy:

1. Prior Authorization and Appeals: In a recent American Medical Association survey, 90 percent of physicians said the prior authorization process delays patient access to care. A health system specialty pharmacy accelerates this process by providing skilled pharmacy liaisons to manage it proactively. Compared to external specialty pharmacies, clinic-based pharmacy liaisons can easily communicate with other providers allowing them to quickly collect and submit required information. This removes the burden of prior authorization from doctors and nurses, who often have limited capacity and time to complete required paperwork.Liaisons in the clinic setting develop personal relationships with patients providing an added motivation to remove administrative burdens and gain health plan approval. And health systems incentivize liaisons to achieve specific prior authorization approval times.

2. High Out-of-Pocket Expenses: Even after cancer patients receive prior authorization, many struggle to access their prescriptions due to the high out-of-pocket expenses related to these therapies. One study found that the average per-claim out-of-pocket costs among 21 oral oncolytics ranged from $15 to $500. Health system specialty pharmacies address this barrier by securing financial assistance from drug manufacturers, nonprofit associations, and other organizations for patients. This support leads to patients starting therapy sooner and staying on it longer.

3. Pharmacy Processing: Finally, health system specialty pharmacies can process and dispense prescriptions quickly. Instead of sending prescriptions to an external specialty pharmacy over the internet or phone, doctors send prescriptions directly to their clinic-based specialty pharmacy team via the health system’s EHR. Pharmacy liaisons then efficiently manage benefits investigation, prior authorization, and financial assistance. Upon health plan approval, the specialty pharmacy team immediately fills the prescription in the on-site pharmacy, and the clinical pharmacist personally gives the medication to the patient when providing drug counseling.

The results of this clinical outcomes study demonstrate the impact health system specialty pharmacies have on important clinical and performance measures like turnaround times. Our partner health systems are currently completing additional studies to evaluate how a clinic-based specialty pharmacy model impacts other clinical and performance measures, such as medication adherence.

Read a clinical outcomes study from Southern Ohio Medical Center or learn about other benefits of a health system specialty pharmacy or contact us to discuss building or expanding a clinic-based specialty pharmacy at your health system. 

1. Given B, Given C, Sikorskii A, Vachon E, Banik A. Medication Burden of Treatment Using Oral Cancer Medications. J Oncol Nurs. 2017 Oct-Dec; 4(4): 275–282.
2. Trellis Rx partner health system specialty pharmacy data

*Turnaround time is defined as how long it takes for a patient to take first dose after the prescription is written

**Health system only evaluated turnaround times for Pfizer oral oncolytics

As chronic illnesses have become more prevalent in the United States, specialty medications to manage these conditions have flourished. According to a recent IQVIA report, a staggering 65 percent of the new drugs that came to market in 2018 were specialty drugs.¹ These therapies can improve care and outcomes, but many patients struggle to start and stay on them for reasons including affordability, healthcare access, and socioeconomic factors.

Health system specialty pharmacies can address barriers to medication access and adherence. Increasingly, hospitals are offering clinic-based specialty pharmacy services to provide high-touch, personalized care to patients with chronic and complex illnesses. This approach leads to better patient care and outcomes, while enabling safety-net providers to make more comprehensive services available to low-income patients.

Affordability is a leading barrier to specialty medication access and adherence

Affordability is a top reason patients fail to start and stay on specialty therapies. Though the average copay for a specialty prescription is $99, annual out-of-pocket costs can be significantly higher for patients with chronic and complex conditions.² The Kaiser Family Foundation found that individuals covered under Medicare Part D in 2019 face out-of-pocket costs ranging from $2,622 to $16,551 for hepatitis C and leukemia specialty medications respectively.²

Unsurprisingly, high costs keep many patients from taking drugs as prescribed. This challenge is greatest for the 30 million uninsured Americans.³ In 2018, uninsured Americans were three times more likely than adults with private coverage to delay or skip a prescription because they couldn’t afford it.⁴ Unfortunately, as the number of uninsured Americans continues to grow, this challenge is only becoming more acute.⁵

Yet having insurance does not guarantee the ability to afford specialty drugs. In a 2016 survey, one-third of Americans without continuous insurance coverage and 14 percent of insured Americans reported skipping doses or not filling a prescription due to costs.⁵  The situation is even worse for patients with chronic conditions. In the same survey, one in four American adults with chronic illnesses reported skipping medications because of costs.⁵

Socioeconomic factors also affect patients’ ability to access specialty drugs

Other obstacles also make it difficult for patients to get specialty medications. These barriers include education, language, and socioeconomic factors such as low income, food or housing insecurity, and limited vehicle access. In fact, a recent study found that prescriptions for children from zip codes with high poverty rates and low vehicle access are significantly less likely to be filled.⁶

Inability to access healthcare is another challenge that causes many patients not to start or stay on specialty therapy. Increasingly, hospitals in rural communities are filing for bankruptcy, creating “health hazard zones.” Patients in these areas are left with limited access to doctors, especially specialists who can prescribe and help them manage specialty medications.

Clinic-based health system specialty pharmacies offer a solution to access challenges

Clinic-based health system specialty pharmacies are improving access and adherence to specialty medications by addressing these barriers. Unlike external specialty pharmacies that rely on strangers in remote call centers, fully integrated specialty pharmacies provide the high-touch, personalized care patients need to start and stay on specialty drugs.

Clinic-based programs are centered on direct pharmacist-to-patient engagement. This model embeds pharmacists directly alongside doctors and nurses to provide in-person education and ongoing support to patients requiring specialty medications. Pharmacy liaisons also work in specialty clinics to manage prior authorizations, refill reminders, prescription deliveries, and more.

One way clinic-based specialty pharmacies improve access for patients is by securing financial assistance from pharmaceutical companies, patient groups, and other organizations. At Southern Ohio Medical Center, a 222 bed hospital located 85 miles from a major city, these efforts helped lower the average patient copay to just $0.38.⁷ One patient wrote a thank-you note to her pharmacy liaison, saying “You can never know how grateful I am for what you’ve done for me. I would pretty much be bankrupt if I had to pay for these drugs if it weren’t for you.”

Specialty pharmacy team members also improve access by connecting patients with other social services to address socioeconomic barriers such as homelessness, lack of food, and lack of transportation. Because clinical pharmacists and specialty pharmacy liaisons work on-site, they can easily collaborate with the hospital’s case managers and social workers to connect patients with needed social services.

In addition to improving medication access, research has found that clinic-based specialty pharmacies drive better time-to-therapy and higher therapy completion rates compared to other approaches. Getting patients on therapy sooner and keeping them on it longer is key to enhancing health outcomes, which can improve patient satisfaction and reduce the overall cost of care.

Specialty pharmacy programs allow 340B health systems to extend care to more patients

In addition to improving patient care and outcomes, offering specialty pharmacy services enables health systems participating in the 340B drug pricing program to extend care to more vulnerable patients.

The purpose of the 340B drug pricing program is to allow participating safety-new providers to “stretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services.”⁹ Participating organizations purchase outpatient drugs from pharmaceutical manufacturers at a discounted rate and use the savings to enhance care and outcomes for underserved patients.

340B hospitals and clinics can significantly increase their savings by bringing specialty pharmacy services in-house. Examples of how health systems invest their savings include starting meds-to-beds programs, offering patient assistance funds, or opening HIV and hepatitis C clinics.

Ultimately, clinic-based health system specialty pharmacies help patients overcome common barriers to specialty medication access to drive improved patient outcomes and better medication adherence, while increasing revenue opportunities for the health system. Watch this short video from Southern Ohio Medical Center to see the positive impact an in-house specialty pharmacy program can have on your community.

Ted Slafsky M.P.P. serves as a policy advisor to Trellis Rx. He is one of the nation’s leading experts on health care policy and access, pharmaceutical pricing and the hospital industry. Based in Washington, D.C., Mr. Slafsky is founder and principal of Wexford Solutions where he consults with businesses and non-profits looking to strengthen their position in the marketplace and improve health care outcomes. Previously, he served as President and Chief Executive Officer of 340B Health, an association of close to 1,400 hospitals participating in the 340B drug discount program.

1. 1. https://www.axios.com/tag/specialty-drugs/
   2. https://www.kff.org/report-section/2018-employer-health-benefits-survey-section-9-prescription-drug-benefits/
   3. https://www.cdc.gov/nchs/fastats/health-insurance.htm
   4. https://www.commonwealthfund.org/publications/issue-briefs/2017/oct/paying-prescription-drugs-around-world-why-us-outlier
   5. https://news.gallup.com/poll/246134/uninsured-rate-rises-four-year-high.aspx
   6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869333/
   7. Based on average copay for patients using Southern Ohio Medical Center Specialty Pharmacy in April 2019
   8. https://www.hrsa.gov/opa/