Ask the Innovators: Stop Looking in the Rearview Mirror of Specialty Pharmacy

SPEAKER_1 (0:01)

Welcome to the Pharmacy Innovators Podcast, brought to you by Visante. We talk with forward thinking leaders who are reimagining what's possible in health system pharmacy. Each episode delivers timely insights to help health systems optimize performance and transform health care through pharmacy.

Jim Jorgenson (0:17)

Welcome to the podcast. I'm your host, Jim Jorgenson. And today I'm joined by Visante specialty pharmacy experts, Angie Amado and Joe Cesarz. We're gonna talk about why health systems can't manage specialty pharmacy by looking in the rearview mirror.

I know you guys have both been on the show before, but welcome back.

Joe Cesarz (0:35)

Thanks, Jim. Good to be back.

Angie Amado (0:37)

Thanks, Jim. Great to be here.

Jim Jorgenson (0:39)

So let's start with a big picture question and the obvious question. Why do you say health systems can't manage specialty pharmacy by looking in the rearview mirror?

Joe Cesarz (0:48)

I think, Jim, we've always been at specialty pharmacy for a while here at VESA and across health systems in the country. So we spent a lot of time building these programs and really looking at how do we grow things from the ground up. And we've entered into an era where things are more competitive and it's harder to really get those gains within specialty pharmacy. So a lot of what we're going to talk about today is thinking about how do you have data monitoring and metrics to be more proactive in the marketplace so that you understand when there are changes.

You can move quickly. I mean, it's not something that you're going to be delayed for two to three months in doing that, but you can really identify them and move within a month so that you can capture that business or kind of modify your approach to take advantage of the marketplace.

Angie Amado (1:32)

Absolutely, Joe. It goes unsaid that specialty is changing almost daily these days. When you look from a payer perspective, from a drug perspective, just understanding the landscape and staying up to date with it is important. And again, having the visibility into how your program is performing, the data, and really using that data to your advantage are definitely topics we want to cover today.

Jim Jorgenson (1:54)

What do you guys think has changed over the last few years that's really making this much harder?

Angie Amado (1:58)

Definitely seeing from a payer perspective, we've always known that that is a complex factor in regards to reimbursement, and regarding how you are set up and what contracts you're enrolled in. I will say more and more, those contracts are getting more and more complicated. Updates are given maybe via fax, and so just staying in tune and understanding what changes from that perspective is really important. So again, from a payer perspective, is being able to monitor those changes and understanding how your health system is impacted by that. Definitely tied from a payer perspective is prior authorization requirements and what that looks like. Again, being able to track and trend denials and what's happening from a day-to-day perspective is important to really see what's changing and what will change overall.

Any others, Joe?

Joe Cesarz (2:49)

No, I think you hit it. I mean, there's, as we know, struggles on the buy side. So just looking at costs and what we can purchase drugs at, we're not going to get into 340B too much today, but that's a constantly evolving area that really impacts margins that 340B eligible institutions are able to buy drugs at. But also overall, the longer that drugs are on the market, as we see biosimilars and some of these kind of race to the bottom from a pricing perspective within specialty, which is relatively new in the marketplace.

You do have those buy side challenges. Then conversely, on the sell side, to your point, lots of challenges with getting prior authorizations approved. We're seeing denials more often. Obviously, PBMs like to audit specialty pharmacies, so a lot of work and administrative effort put in there. But then also just the reimbursement rates. Once again, it's harder and harder in specialty pharmacy. You have to be more competitive and really thinking about how do you run an efficient operation so that you can leverage the margins that we see within the marketplace to really be profitable and to continue to grow.

Jim Jorgenson (3:53)

You know, with so many moving parts, what's the biggest mistake you see health systems making today regarding specialty?

Angie Amado (3:59)

I think it goes unsaid. A lot of times, health system leaders are bogged out in the day to day and maintaining the program and really not focused from a financial standpoint and kind of looking after the fact and having reports that are delayed a month, a quarter, depending on the turnaround times and when these reports are generated. And so that's a big area of concern and that we see across our clients to really not be in tuned and really doing deep dives to their data in a more proactive basis. A lot of times, once these reports are generated, they are not able to have the visibility in regards to changes until after the financial impact is made.