04/30/20 Excelera

The Importance of Payer Access to Health System Specialty Pharmacies

By Meredith Holt, National Vice President of Sales

Key Concepts 

  • Health system specialty pharmacies typically experience high lost script rates, meaning they are contractually unable to dispense specialty medications to patients who are referred to them and must transfer the prescriptions to another specialty pharmacy.
  • Challenges to accessing managed care contracts include specialty drug lock-outs, narrow networks and other industry trends.
  • The solution to gaining payer access at the specialty pharmacy level is to pursue highly targeted contracting, supported by data-driven analysis.
  • The Excelera Payer Access Program can provide health system specialty pharmacies with the specialized contracting expertise they need to reduce lost script rates and ease the fragmentation of care.

According to Specialty Pharmacy Times, fill rates for specialty pharmacies in the U.S. range between 25-46%, resulting in the transfer of approximately 55-70% of referrals received. For health systems with specialty pharmacies, this market dynamic creates not only operational workflow obstructions and loss of revenue, but fragmentation of patient care, from patient confusion and inconvenience to serious delays in time to therapy.

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 on several fronts.

Challenges to payer access

Health systems have long been frustrated by specialty drug lock-outs in PBM contracts. Similarly, the use of narrow networks by plan sponsors is increasing, with employers restricting their covered employees to specified national chains; consolidation in the industry means these chains are fewer, larger and have more leverage. For 340B health systems, some payer contracts include an addendum encroaching on 340B drug pricing.

Other challenges arise with specialty medications that are covered by more than one benefit—medical, home infusion, specialty, drug—adding to the complexity and potential for errors and confusion. Home infusion itself is a trend with consequences for specialty pharmacy; the continuing growth in home infusion may result in a declining hospital census and even a reduction in use of outpatient infusion centers, depending on local demand. Health systems without a home infusion pharmacy risk losing those prescriptions.

Addressing the need for access to payers

The solution to gaining payer access is to pursue highly targeted contracting, supported by data-driven analysis, at the specialty pharmacy level. Analyzing existing specialty pharmacy contracts and hospital payer contracts, as well as all referrals received by the specialty pharmacy, reveals insights on where gaps exist.

Based on this analysis, the local health plans and employers with the highest rate of referrals to pharmacies outside of the health system can be targeted. Top employers are interested in differentiating their benefits to attract and retain employees, and they may welcome the opportunity to eliminate waste while ensuring integrated care from a health system partner that is widely embedded in the community and dedicated to serving that community.

Developing a blueprint for payer access

The Excelera nationwide network of health systems offers a range of products and services to help health systems deliver care to complex patients. One of these, the Excelera Payer Access Program, provides expert education and analysis, identifies health plan and employer targets and the ideal payer mix, cultivates contractual agreements, and provides reporting to, and on behalf of, the health system. The Excelera Payer Program allows health systems to tap into specialized contracting expertise and capabilities that most do not have internally. It is available to both member and non-member health systems to help reduce lost script rates, increase fill rates and minimize fragmentation of care.

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

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