News

05/29/20 Excelera

New Program Develops and Implements Customized Payer Access Blueprint for Health System Specialty Pharmacies

By Meredith Holt, National Vice President of Sales

Key Concepts

  • Payer access is a significant barrier to delivering care to complex patients.
  • Gaining and retaining access to payers is challenging for health system specialty pharmacies.
  • The Excelera Payer Access Program provides expert education and analysis, identifies high-value targets and the ideal payer mix, cultivates contractual agreements, and provides reporting to, and on behalf of, the health system.
  • The Excelera Payer Access Program helps health system specialty pharmacies capture more specialty pharmacy dollars, reduce lost script rates, increase fill rates and minimize fragmentation of care.

One of the significant barriers to delivering care to complex patients is payer access. Health system specialty pharmacies (and other independent specialty pharmacies) frequently transfer referrals to other specialty pharmacies, not because of patient preference or convenience, but because the patient’s pharmacy benefit restricts where the prescription may be filled. The Excelera Payer Access Program is an innovative consultative offering that helps health systems capture a greater share of the specialty pharmacy opportunity and deliver a superior patient experience by minimizing fragmentation of care.

Challenges

Having access to managed care contracts is key to increasing fill rates, correspondingly reducing lost script rates and minimizing fragmentation of care. However, gaining and retaining contractual access is challenging, for reasons ranging from PBM specialty drug lockouts and narrow pharmacy networks to the growth of home infusion and the increasing number of drugs being injected rather than infused. The Excelera Payer Access Program provides health systems with the expertise and insights to meet these challenges.

The Excelera process

The Excelera Payer Access Program provides expert education and analysis, identifies high-value targets and the ideal payer mix, cultivates contractual agreements, and provides reporting to, and on behalf of, the health system. The combination of market education and active payer engagement minimizes the fragmentation of patient care associated with poor managed care contracting access.

  • Education: The process begins with market education. Excelera provides insights on hospital and specialty pharmacy trends, payer contracting trends and reporting trends. Excelera consultants also assess the current specialty pharmacy market for the health system, by therapeutic category and payer mix.
  • Analysis: Excelera consultants analyze existing specialty pharmacy contracts and conduct a gap analysis, identifying the ideal payer mix of Commercial, Medicare Part D, Managed Medicaid, risk management groups and PBM. They work to align specialty pharmacy contracts with hospital payer contracts, and they request and review all referrals received by the specialty pharmacy to identify the current fill rate and the current lost script rate. Lost script referrals are analyzed by therapeutic category, referral source and payer.
  • Payer Contracting: From this framework of knowledge, Excelera is able to prioritize high-value payer targets based on referral volume and access point.  Payer access and profitability are achieved by developing a robust market access strategic platform that prepares pharmacies to meet network access requirements, brokering relationships with payers for specialty pharmacy contract access, and providing expertise in negotiating contract terms. This methodology increases pharmacy fill rates and streamlines the referral intake process for the internal stakeholders within the specialty pharmacy.
  • Reporting: The program provides quarterly reports on margin and revenue, broken out by therapeutic category, and meets reporting requirements to payers on behalf of the health system, to ensure compliance and avoid penalties.

Conclusion

The Excelera Payer Access Program allows health systems to tap into specialized contracting expertise and capabilities that most do not have internally, helping them capture more specialty pharmacy dollars, reduce lost script rates, increase fill rates and minimize fragmentation of care. The positive impact reaches beyond the specialty pharmacy to benefit the health system as a whole.

To learn more about our Payer Access Program, contact us.



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