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“The collaboration between ACOs, payors and specialty pharmacy will be extremely important to the cost of care. Collaboration with specialty pharmacies on long-term patient management when specialty drugs are necessary will help achieve the desired outcomes that most payors/ACOs are looking for in today’s world,” says Colleen Lindholz, President, Kroger Health.

Kroger Health  is a solution provider at the marcus evans ACO & Payer Leadership Summit 2021.

What are some of the biggest challenges that specialty pharmacies face today, regarding the payor landscape? 

Lindholz: Continued reimbursement pressures to control payer costs - while increasingly requiring accreditation, clinical programs and reporting to participate in networks - are adding cost to pharmacy providers. The limited and narrow networks used to control cost create frustration for members and providers to route prescriptions appropriately, delaying therapy start, limiting choice, and reducing opportunity for physicians to manage patients through a few pharmacies vs. many.

Changing clinical requirements and formulary preferences are also challenging when not consistently applied or communicated to providers, preventing pharmacies from acting as intermediaries for physicians to submit clinical information for authorization, and/or changing preferred medications increase turnaround times to get medication to patients, creating dissatisfaction for patients and providers.

How is specialty pharmacy adapting to new requests for adherence data and patient monitoring from the payor landscape?

King: Reporting of patient adherence, clinical outcomes, and data monitoring on disease specific dimensions are new trends that many specialty pharmacies are now being requested to align with payor organizations. These items pose many challenges that stem from a lack of standardization in reporting, thus increasing cost. The monitoring of medication for a specific patient population is one area where specialty pharmacy can help with patient compliance. Clinicians within a specialty pharmacy can continuously speak with patients to follow up on adherence and note that detailed information. The data and assessments can be collected on the clinical outcomes of a specific patient population.

What advice do you have for a payor or ACO to work successfully with a specialty pharmacy?

Lindholz: Collaborating on value-based programs promoting drug adherence, ensuring appropriate dosing and utilization management will be extremely important to the cost of care. Many times, the process of communicating between a specialty pharmacy and a payor/ACO takes several days to complete because there is not a direct line of communication. Collaboration with specialty pharmacies on long-term patient management when specialty drugs are necessary will help achieve the desired outcomes that most payors/ACOs are looking for in today’s world. This type of partnership could enrich customized clinical programs with measurable outcomes that leverage health assets to lower cost of care and shift care to lower cost, safe alternatives.

What vision of healthcare should ACOs and payors be most concerned with moving into 2021 and beyond?

Lindholz: The healthcare industry continues to evolve rapidly as costs continue to climb. Generally, we anticipate ongoing scrutiny of drug prices, decreased participation of manufacturers in 340B programs, price transparency, a decline in the number of pharmacies, as independents are unable to retain profit to stay afloat. As the economy looks to recover, we anticipate small businesses and consumers will lack healthcare insurance or carry high deductible plans, while the payers will continue to look for ways to reduce costs and mitigate risks, partnering with organizations like Kroger Health that offers more than the basic fulfillment of a prescription. Collaboration between payors, specialty pharmacies and providers will be key to success.

Specialty pharmacy has many challenges in approving medications for an aging population. How can this be handled in a simplified manner?  

Lindholz: As payers and ACOs continue to look for ways to increase formulary adherence and move patients to preferred formularies, partnership with EMRs and companies like Kroger Health that are rich in both clinical and consumer data, will be essential in directing providers to preferred treatment protocols, and will accelerate clinical reviews and/or appropriate medication switches.

King: Additionally, allowing pharmacies to submit prior authorization requests based on the clinical information received at intake would also reduce time to get the same information from the physician staff, while also reducing the administrative burden on the providers. With most patients having the need to be on multiple medications, specialty pharmacies would benefit by working collectively with payor organizations by sharing information on a specific patient who might have previously been on a medication. This could expedite the process to dispense a new medication.   

 Ahead of the marcus evans ACO & Payer Leadership Summit 2021, Colleen Lindholz and John King discuss why collaboration between payors, specialty pharmacies and providers will be key to success  

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