A Successful Health System Pharmacy Strategy Starts with Access to These Three Things

For a number of years now, the conversation on building or expanding a specialty pharmacy line has shifted from one of importance and impact to one of possibility and practicality – meaning, the questions of whether a health system needs a specialty pharmacy (answer: yes, for most) and why (answer: the promise and potential for improved patient outcomes, increased retention, and critical revenue opportunities) have been widely accepted, and now it’s the how, what, where, and who that are being actively explored in many systems. Solving for these aspects of specialty pharmacy success often begins, in one way or another, with access.

As Ginger Thorpe, Vice President General Manager of Pharmacy Solutions in Health Systems at McKesson puts it, “Access is a three-pronged approach. The health system should be thinking through all three in parallel – access to the patient [prescription], the payer, and the drug. Without any one of the three, critical opportunities will be missed.”

Patient/prescription access 

When speaking to patient access, Ginger clarifies, “The health system may have the patient sitting in their facility. The health system provider may prescribe the medication to the patient. But that doesn’t always mean the health system ends up filling the prescription. Patient access really means prescription access.”

While it may seem like an obvious path from having a drug prescribed in the health system to having the patient fill the prescription in the health system’s specialty pharmacy, there are a number of turns that can be taken – and external factors – that can result in another outcome. For one, patients may be eligible for financial assistance but unable to navigate it. Or, they may in fact want the convenience of a system-owned specialty pharmacy but find coverage barriers that send them elsewhere. Perhaps the most sweeping across health systems, yet simultaneously the simplest to address, is the lack of awareness that filling a specialty prescription in house is even an option. Even more serious than missed revenue opportunities due to a break in patient/prescription access is the disruption in care continuity that can result, as providers lose visibility into the patient’s disease progression or otherwise.

Payer network access

Even in a situation when the patient is 1) aware of the health system’s in-house specialty pharmacy, 2) prefers to fill their prescription within the health system, and 3) is able to – or has the assistance to – navigate the process and potential assistance accordingly, payer networks are often the ultimate decision-maker when it comes to defining where prescriptions can be filled. There’s little debate that gaining access to these networks can present one of the most complex challenges health system specialty pharmacies face today. Many payer plans have tightly managed specialty networks, and without access or inclusion, prescriptions are inevitably diverted elsewhere.

This is where a deliberate strategy – and the appropriate data – become indispensable. Understanding your current referral leakage, identifying which payer contracts may be responsible for lockouts, and quantifying those revenue gaps are some of the most important steps you can take in preparing your health system to pursue wider network access.

Drug access

The third area of access – though not in a hierarchical sense – for health system specialty pharmacy success is having access to limited distribution drugs (LDD), and the right ones as they pertain to your patient usage and prescription data. Without the appropriate portfolio, even payer and patient access cannot translate into filled prescriptions nor the ultimate goals of improved care outcomes and financial growth or viability. Ginger illustrates a comparison of both scenarios – one where the health system has appropriate LDD access and one without: “When a health system is missing that critical component of LDD access, there can be a cascade effect: patients are diverted elsewhere, care becomes fragmented, outcomes may worsen, and revenue is lost, which further compromises the ability to provide care. Conversely, gaining entry to those LDD channels can help stabilize retention, support care and outcomes, and also becomes a proof point that the health system is capable of supporting the advanced therapies their patients are asking for.”

3 is key – but 4 is more 

Individually – patient, payer, and drug access represent enormous hurdles in their own ways, but each is woven in with the next and all are essential for success – both in terms of capturing opportunities and better serving patients. Collectively, however, they can create a complex ecosystem that many health systems find exceptionally difficult to solve for on their own.

With that, Ginger suggests the addition of a fourth pillar to the three-pronged approach: strategic partnership. “We are here to help health systems uncover those opportunities, to unlock access to the right networks and LDDs, and to celebrate the successes they’re already achieved on their own.” By partnering with our Specialty Pharmacy Enablement (SPE) experts, McKesson Health System customers can achieve more through:

• Leveraging data to map where patients are being lost and why
• Using our expertise and networks to expand payer network access
• Tapping into our team’s in-depth understanding of requirements and limitations regarding LDD access

Ginger leaves us with an analogy, “Think of it this way: access to patients, payers, and drugs is like the foundation of your house. But the foundation on its own doesn’t make the house livable. You’ve got to build a structure on top – in this case being the expertise, the design, the strategic guidance – to go from pouring the foundation to actually living the reality.”

To learn more about partnering with McKesson to achieve more for your health system specialty pharmacy, contact us today.

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This document is intended for informational purposes only and does not constitute medical, legal, or financial advice. The views expressed herein are those of the speaker and do not necessarily reflect the official policy or position of McKesson Corporation or its affiliates. Any statements regarding operational, clinical, or financial outcomes are illustrative in nature and should not be interpreted as guarantees of performance or results.

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References to partnerships, data analytics, or predictive modeling are general in nature and do not imply endorsement or certification by any regulatory authority. Readers are encouraged to consult with qualified professionals before making decisions based on the information provided.

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