As payers focus on managing the proliferation of specialty pharmacy products available in the marketplace, they should look to their specialty pharmacy providers (SPPs) as partners in this endeavor. Payer management of specialty products is heavily focused on restriction through utilization management policies, or in some cases product exclusion. However, these strategies can only go so far, which has led many payers to seek additional strategies to manage spend in these complex populations. SPPs are already relied upon for the efficient distribution of specialty medications, and education and ongoing monitoring of patients receiving a specialty medication. However, payers may further leverage their SPP partners to support their own specialty pharmacy management initiatives.
SPPs play a unique role in the specialty pharmacy patient journey as they generally communicate with the patient at least once per month around refills. This interaction provides an important opportunity for individual patient adherence counseling and monitoring, disease state education, symptom/adverse event identification and management, identification of signs of disease progression, and quality of life assessments between visits with a specialist which may only occur once or twice per year. As payers looks for innovative ways to manage their specialty populations, they may consider opportunities for collaboration and data-sharing with SPPs as a means to develop or enhance their own care management offerings for patients on specialty medications. While these potential partnerships have great possibilities to support specialty pharmacy patients, they do come with many logistical and operational considerations including aligning workflows, data interoperability, and limited resources across stakeholders. As a result, payers and SPPs will be interested in seeing case study examples of how these collaborations can be set up and how barriers can be overcome.
Value-based or outcomes-based contracts have been touted as potential solutions to managing the costs and determining the value of high-cost specialty medications. Despite the excitement around these innovative contracts, few payers have been able to execute due to some of the challenges in operationalizing these agreements. One common sticking point is alignment on an outcome metric for the contract that is both meaningful and measurable. SPPs can fill this gap by collecting patient-reported outcomes data during refill check-in calls with patients and providing that data to the payers. These arrangements may also take some investment of time and resources to implement, but can lead to obtainment of valuable data for innovative contracting purposes.
Improving clinical and economic outcomes for specialty patients often requires the engagement of multiple stakeholder in the healthcare ecosystem. As payers work to find “out of the box” solutions to high pharmacy and medical spend in their specialty populations, they should explore the potential for leveraging the infrastructure and patient rapport of the SPP. Manufacturers should consider how enhanced collaboration between SPPs and payers can support their portfolios and initiatives. As SPPs and payers navigate these new arrangements, they may value manufacturer resources that describe the details of successful partnerships, such as through a case study, or help to support the implementation of these programs.