Tony Hagen is senior managing editor for The Center for Biosimilars®.
In a recent presentation at the Specialty Therapies and Biosimilars Congress, the director of pharmacy for Emory Healthcare discussed how they developed a strong in-house specialty pharmacy and cut dependence on outside for-profit specialty pharmacies and managed to strengthen adherence, improve patient outcomes, and reduce costs.
By developing a strong in-house specialty pharmacy and reducing dependence on outside for-profit specialty pharmacy, Emory Healthcare managed to strengthen adherence, improve patient outcomes, and reduce costs, according to Ryan Haumschild, PharmD, MS, MBA, director of pharmacy for Emory.
In a recent presentation at the Specialty Therapies and Biosimilars Congress, Haumschild discussed the difficulties Emory perceived with outside specialty pharmacy and the measures the academic health system implemented to ensure better coordination of patient care and follow-up, and reinvest the savings to increase gains.
Emory decided to take these steps after noticing that patients were having problems related to assessment, monitoring, and medicine delivery. Providers in the system were increasingly frustrated with poor outcomes, and these issues were traced to the performance of outside specialty pharmacy, Haumschild said.
“Surveys were returned with negative feedback. We had gaps in medication adherence and care. We also had physicians really upset that nobody was coordinating care, and we realized that patients were stuck with really big copays. Patient assistance programs really varied in terms of access to medication,” he said.
Ultimately, he said, “We couldn’t sit back anymore and let someone else provide the care.”
Emory implemented key improvements, such as increasing the involvement of residency trained, board-certified pharmacists in many aspects of the care continuum. This represented an added expense, and pharmacists with this level of qualification are not easy to recruit, owing to marketplace competition, he said.
Further, indoctrinating providers and pharmacists to this new mode of operation and mindset was not an overnight process, Haumschild said. Pharmacists were asked to perform a wider set of duties to which they were not accustomed, and providers and pharmacists had to give up a measure of independence.
But the pharmacists possessed up-to-date knowledge of clinical advances and drug indications and availability—specifically, cost consciousness—and they had frequent interaction with patients throughout the care timeline. They were ideally positioned to work closely with providers and patients to ensure protocols were followed and patients were appropriately monitored and informed.
“Often our physicians are so involved with their practice and investigations that they select higher-cost medicines without really reviewing the literature and seeing what the best outcomes would be. They self-recognized that that there is a lot going on and cancer is becoming a lot more complex,” Haumschild said.
Providers agreed that pharmacists should be involved in multiple patient care scenarios, from treatment plan recommendations to medication follow-up. With this integration of pharmacist expertise and involvement, protocol compliance went from 62% to 100%, he said.
Other problems with outside specialty pharmacy included the way that medication adherence metrics were being calculated. According to the medication possession ratio (MPR), outside specialty pharmacy was doing a good job of getting drugs into the hands of patients, but by filling some prescriptions early and then averaging out the results, these pharmacies were able to inflate the MPR, Haumschild said.
A related problem was that subsequent-cycle medication was being shipped to patients by for-profit specialty pharmacies as soon as payers approved, but without appropriate intervention to ensure that continuing the regimen was the appropriate course. “Patients were taking that subsequent cycle in oncology and having toxicities and having to discontinue therapy,” and the result was that their first-line therapy option was no longer an option. “It was great for the pharmacy, because their medication possession ratio looked great, and they got a pretty good margin off that oncology medication, but our patients were taking the brunt of it,” Haumschild said.
“These metrics can be so deceiving, until you dig into that patient experience,” he said. Now, Emory prides itself on how many times it stops a subsequent prescription fill based on evidence of drug-to-drug reactions, toxicities, and other problems that signify that the medication must be interrupted for patient benefit, he said.
With its in-house program, Emory’s mean MPR improved to 1.00 versus 0.75. An alternate measure of patient drug possession, mean proportion of days covered, improved to 0.95 with the in-house program, versus 0.70 for outside pharmacy.
Adherence outcomes also improved. With high adherence defined as ≥80%, the internal high-adherence percentage was 95.5% versus 70.2%. Low adherence, defined as <80%, dropped to 4.6% in-house versus 29.8% externally.
Time to treatment achieved was 6.85 days versus 10.91 days externally. Although a difference of 4 days may not seem like a lot, Haumschild said, it is when you have patients with stage IV cancer or who might otherwise check into a hospital for costly treatment. “So many times, patients weren’t getting their medication on time and it was affecting outcomes.”
Other metrics that Emory sought to improve included dose accuracy, drug waste and abuse, savings, patient interventions, and outcomes of patient interventions. These were categories of performance that were considered of great value, but in surveys of outside specialty pharmacy the satisfaction ratings were relatively low.
Having concrete data from a systematic review of outcomes enabled Emory to build credence with payers and manufacturers. “You need data to back up your models,” Haumschild said. “If they’re going to give a small health system access that they [previously] limited to only 7 pharmacies, you have to demonstrate that you’re improving outcomes relative to those pharmacies.”
With 11 hospitals in Georgia and 250 locations, Emory was able to demonstrate value relative to outside specialty pharmacy. “We have a large patient base. We’re practically the academic medical center for the state of Georgia, and we service large companies such as Coca-Cola and Delta. We also have a comprehensive cancer center—the Winship Cancer Institute,” Haumschild said.
Further, multiple individuals intervene along the patient care path to guide and manage. These include clinical pharmacy specialists, prior authorization technicians, medication assistance coordinators, and pharmacy dispensing staff. The heavy emphasis on coordination and follow-up may seem like overkill, but it helps to ensure success. If there is a breakdown in one link in the chain, especially at the end, outcomes will suffer, Haumschild noted. In addition, he added, the Emory specialty pharmacy became accreditated.