Integrated specialty pharmacies are making an impact

Integrated specialty pharmacies are gaining traction, particularly medically integrated specialty pharmacies (MIPs), due to enhanced patient outcomes and demonstrated value, according to Karen Thomas, associate director, specialty and infusion pharmacies and clinical assistant professor at the University of Illinois Chicago.

Karen Thomas, associate director, specialty and infusion pharmacies and clinical assistant professor at the University of Illinois Chicago

“MIPs improve patient outcomes by providing comprehensive care coordination and support of the patient along the whole patient journey,” she said, adding that better medication access and adherence are driving forces.

“Some patient advocacy groups and caregiver associations have also been vocal about the benefits of integrated pharmacies. Some manufacturers are listening and offering more access to limited distribution drugs, which I am so grateful for,” she said.

However, one area where she hasn’t seen much of a shift is with pharmacy benefit managers (PBMs).

“PBMs are often vertically integrated with traditional specialty pharmacies (in that they are owned by the same company), which gives PBMs less incentive to have their patients use an MIP,” Thomas said. “Hopefully, we can see that shift if employer/employee groups advocate for integrated pharmacy use in their contracting with PBMs.”

In an exclusive interview with Access Insider, Thomas discussed the dynamics of integrated specialty pharmacies.

How have you seen the pharmacy landscape evolve over the past few years, particularly regarding specialty pharmacies?

Thomas: As with most things, the constant in the pharmacy landscape is change. There are always new medications, treatments and ways to help patients, which is exciting because there is always something to learn and hope to give.

My career has been focused on outpatient pharmacy, caring for patients who are not in the hospital, and so therefore that is the primary part of the landscape I can comment on. Since I graduated, it seems like there is always more to do but not as many resources to get that work done; I think we see evidence of that with shifts in how bigger pharmacy chains are managed/combining/having difficulty keeping staff, and that there have been many independent pharmacy practices going out of business.

Retail and specialty pharmacy business are very strongly influenced by reimbursement from pharmacy benefit managers (PBMs) and insurers. Automation and computing power have enabled more utilization management programs which are used by PBMs and insurers to control how much they spend on patient care.

One tactic to control spend is to require prior authorizations. Another tactic is to drive specialty prescriptions to specialty pharmacies that are contracted with insurance plans. What this means is that many patients do not get to choose the pharmacy that dispenses their specialty prescription, and instead their insurance will require them to get their medication from a specific pharmacy. Some patients do still get to choose and those are patients that are usually served by medically integrated pharmacies.

Contracts have become less favorable for pharmacies over time and often pharmacies will lose money when filling prescriptions for a patient. However, specialty medications tend to have better reimbursement rates. Over the past five years or so, specialty medications have accounted for about 50% of drug costs while only making up 2% of the medications that are actually dispensed. So it makes sense that this would be an area of focus for managing costs.

Another thing that is changing is that PBMs and insurers seem less likely to allow small pharmacies to fill specialty prescriptions for their patients. This was initially enforced by requiring a single specialty pharmacy accreditation; and then a couple of years later, most payers required a second pharmacy accreditation to continue to fill for patients. After a while, pharmacies had to apply to be part of the specialty pharmacy network for big insurance companies; those applications are very time consuming and not a guarantee that a pharmacy will be able to fill for particular patients. So it is getting tougher to be able to care for specialty pharmacy patients if you are not at a big specialty pharmacy.

The other nuance is that some medications that are considered “specialty” medications by insurers may not be available to all pharmacies. There are some medications, usually medications for rare or orphan conditions, or medications with particular side effect profiles, that are only available at certain pharmacies. Called limited distribution drugs, this distribution model decision is made by a manufacturer. As more medications for rare or orphan conditions are approved, there are more medications with limited distribution networks. This seems to have become more prevalent over the past decade.

How do MIPs work and what unique advantages do they offer?

Thomas: I would define MIPs as pharmacies that are operated within or closely associated with a healthcare facility, like a hospital or clinic. MIPs are funded by dispensing activities as well but often have some additional financial support from the health system or clinics they are associated with (but not always). They also may have access to 340B savings if they are affiliated with a covered entity, which can subsidize some of the comprehensive care they provide to patients. This difference in how traditional specialty pharmacies and MIPs are structured can sometimes influence primary goals in their workflow — traditional specialty pharmacies want to dispense more prescriptions to any patient anywhere because they are a business and that is how successful businesses operate, and MIPs want to provide excellent wraparound care to the patients in their system.

For a patient to get a prescription filled, there are at a minimum four parties involved that have to coordinate: the prescriber, the patient, the patient’s prescription insurance plan, and the pharmacy. With specialty pharmacies, this gets more complicated because it requires a specific pharmacy and additional paperwork before the patient can get their medication. Also, their copay may be higher than for a more common medication. When the prescriber and the pharmacy are in the same place and the patient is familiar with the system, it is a little easier to coordinate everything and generally this ease results in faster access to the medication and faster response if the patient has a medication related problem.

I work in a health system specialty pharmacy, which is a MIP that is part of a health system. MIPs typically have full access to the medical records for the patients that our pharmacy fills medications for, a physical proximity to the clinic, likely a personal relationship with the clinic staff caring for the patient, and the patient has familiarity with the system. This gives MIPs the advantage of being able to understand more about the patient’s medical history, needs, what they have tried before, etc., and also the advantage of being able to communicate directly with the prescriber if there are questions or concerns. For example, I can call the pharmacist embedded in the clinic to coordinate care for a patient if I need to.

Additionally, health systems often have pharmacists that are part of the patient care team in the clinic — alongside nurses and doctors — and they are often involved in treatment decisions as well. If there are a couple of options for the patient, often the pharmacist or pharmacy technician will be responsible to find out what is covered by the patient's insurance. We can do a test claim at the pharmacy to check if the insurance requires a prior authorization and then complete the prior authorization paperwork. This helps make sure the patient can get their medication as soon as possible. Sometimes if the patient is required to fill at a traditional specialty pharmacy, they won’t have that relationship with the pharmacy, or there may be lost time when the pharmacy is trying to contact the patient, but the patient doesn’t understand that they have to go to the external pharmacy and maybe won't answer the phone.

Sometimes a prescription will be sent to a traditional specialty pharmacy, but the prescriber will not anticipate that it requires a prior authorization. This requires a back and forth between the external pharmacy and the clinic to just get that paperwork done. If the integrated pharmacy staff can identify that right away, they save time. Any time that we can save in accessing medication is important because patients on specialty medications often have serious or debilitating conditions (like cancer or autoimmune arthritis) and the sooner we start medication, the sooner they can feel better or have improvement. If there are delays, their condition may progress, and they may have worse outcomes.

How do you think MIPs improve patient outcomes?

Thomas: Integrated pharmacies are intertwined and frequently coordinating with the patient care team to ensure that the patient gets the holistic care they need — if the MIP pharmacy identifies a barrier for the patient related to a social determinant of health, often they can coordinate to help the patient access clinic or system resources for support. Traditional specialty pharmacies also support the patient on part of their journey — educating patients and dispensing medication — but the patient is more than just their medication or condition, and they may need additional support from clinic staff, which can be very hard for traditional specialty pharmacies to engage.

Of note, many medically integrated pharmacy teams will provide care along the whole patient journey with the exclusion of the medication dispensing step if the system has the resources to do it. Meaning that often a patient will have care from the medically integrated pharmacy team even if that team is not able to dispense the medication. This is because the care model at the clinic provides support for all patients of the provider regardless of where that patient gets their medication filled. This makes it tough to tease out outcomes for patients that are cared for by MIPs as compared to traditional specialty pharmacies because overall, the patients cared for by medically integrated teams have positive outcomes and many of those outcomes are influenced by the care that is provided along the whole journey, not just the dispensing step.

Additionally, it is hard to compare outcomes between MIPs and traditional specialty pharmacies because the data is not always readily available.

I am probably biased, but I think that this care model is incredibly valuable to patients. My mother had breast cancer a couple of years ago after being healthy for a long time. She and my dad struggled to navigate and come to terms with the diagnosis, and while that was going on, she was able to get all her care within the same system, including a MIP. This helped so much because she did not have fragmented care, which means she was able to use a single pharmacy for all of her needs, get chemotherapy and radiation in the same system where her doctors were, and her medications were managed. So when she had to manage the side effects of her chemotherapy with medications, the clinic could see when she had her medication dispensed, ensure that insurance was helping her pay for it, and help her feel her best. The transparency made a difference. Even with everything being in the same system this was such a tough experience, and I know she could have navigated having to use a different pharmacy, but it would have added an unnecessary layer of stress and complexity.

There are many success stories for both MIPs and traditional specialty pharmacies, and we should celebrate all of them while recognizing that there are always opportunities to improve the care we provide to patients. This is why it is important to talk about different care models and do objective analyses of the ways we care for patients to make sure we are doing everything we can to support optimal outcomes.

Hear Karen Thomas speak more about integrated pharmacies at our upcoming conference.