Specialty pharmacy presents tremendous opportunities for community pharmacies, but is also perceived to present serious challenges.
You may know that you have a handful of patients for whom you need to dispense specialty medications; you may sense a real market opportunity to meet a broader demand for community-based specialty programs; or you may even have a vision of building up a specialty business that serves patients across the country. Each of these models has specific demands, and each one can be successfully pursued using specialty pharmacy software platforms in the market right now. Hear from two pharmacies making these models work, and from the software vendors providing the right tools for each model.
Chris Antypas, Pharm.D., is president of Valeda Rx, an independent national specialty pharmacy based in Pittsburgh, Pa. The pharmacy is licensed in 49 states and the District of Columbia, with California pending. Valeda Rx moved into specialty in late 2016, using ScriptMed from Inovalon as its software platform. “Our goal as an independent specialty pharmacy,” says Antypas, “is to take care of people effectively in what is a very difficult and challenging part of the pharmacy market. We chose ScriptMed because it has extremely robust capabilities in particular for data collection, data reporting, and managing our patient care workflow in a very customizable way.”
MaryHoa Luu-Yik, Pharm.D., is the senior clinical care pharmacist at ProCare Pharmacy in Garden Grove, Calif., which started with specialty pharmacy in 2018 and shortly thereafter decided to begin using the APCS platform from ScriptPro to handle patient management and care documentation. “We have seen the need for us as a community pharmacy to become a specialty pharmacy,” says Luu-Yik, “because specialty medications are very intricate and very high in cost. They require monitoring and counseling to prevent wastage and to improve efficacy. Big chain stores and mail order can’t provide the same level of patient care that we can, especially because many of our patients speak Vietnamese.”
Why Specialty Pharmacy Needs Technology
Rinku Patel, Pharm.D., SVP of specialty business at Transaction Data Systems, which is owner of the KloudScript KETU specialty pharmacy platform, sees the biggest challenges for pharmacies launching specialty as not knowing the features and capabilities of a patient care management system. “They may not fully realize that the technology they are about to select must support not just clinical needs for disease and drug specific care, but also must support financial aspects of managing hub services,” says Patel, “and manage third-party reporting requirements of pharma, payers, or accrediting bodies.”
As Ernie Shopes, SVP of product and client delivery for Inovalon, points out, the therapy, clinical, and patient management required in specialty pharmacy is quite complex, much more so than for dispensing a non-specialty medication. For example, there’s the task of referral management, also known as case management, which is really the intake process for a new patient or a new prescription for an existing patient. A specialty pharmacy will need to ensure that it is capable of efficiently handling and documenting a broad array of requirements for a variety of partners, from payers to manufacturers to prescribers.
For a very simple example, Shopes points out that 80% or more of specialty drugs require prior authorization. Then there’s the fact that, while many typically fall on the pharmacy benefits side, there are also those that fall on the medical benefits side, with all of the accompanying complexities.
And, Shopes notes, because of the high cost of specialty medications, many patients have supplemental insurance or require financial patient assistance programs, which leads to a coordination-of-benefits element both for eligibility verification and billing.
Finally, clinical management can have an overlay of payer requirements to demonstrate, for example, the attention given to adherence and quality of life. “Specialty really requires a highly configurable workflow that allows you to drive the right tasks in the right order,” says Shopes.
Establishing Specialty Pharmacy Programs
When you are in the specialty pharmacy market, you need to research and build out the programs required for dispensing specific medications. A specialty pharmacy software platform plays a crucial role here, as does the support of the platform vendor.
For example, as MaryHoa Luu-Yik describes it, ProCare Pharmacy’s APCS platform offers a manual process for creating new, customized clinical programs, with all the required rules and flags needed. A specialty software vendor should also be your active partner with ongoing supports and services, notes Luu-Yik. She works with several ScriptPro staff members, speaking with them every two to three weeks. One part of these conversations is getting up to speed on any new specialty programs that ScriptPro’s in-house clinical team has set up. Being able to use a prebuilt program like this within APCS is a big help, according to Luu-Yik, since it removes any guesswork and lets ProCare Pharmacy hit the road running with new programs for patients. This kind of support from the specialty software platform vendor is going to be missing if you try to cobble together the tools you need in a do-it-yourself manner.
For a further example of the resources specialty software vendors bring to the table, Rinku Patel explains that KloudScript offers full-service hub support that manages some of the back-office work for pharmacies. “The hub means that pharmacies don’t necessarily have to build a huge team or have a lot of capital to invest to start up specialty programs,” Patel says. “We keep all of the clinical data and the associated workflows up to date, and those details are automatically pushed out in the system. And with a tool like our RxWise Patient Assistance Programs data, we are able to provide pharmacies with generally accepted prior authorization criteria, what patient assistance programs are available, and other important details that help shorten the turnaround time in gaining coverage and dispensing a patient’s specialty prescription to just hours or days, rather than weeks or sometimes even months.”
Having access not just to software, but to these kinds of services as well, means that a pharmacy doesn’t necessarily have to build a bigger team of clinical pharmacists to manage and maintain all of the various therapeutic categories that they may be dispensing just by subscribing to a platform.
Pharmacy Workflows for Specialty Therapy Management
And once the platform is in place and you are working to keep the program requirements up to date, then what about the actual nuts and bolts of specialty pharmacy workflows? Retail pharmacy systems have increasingly sophisticated workflow and patient care management capabilities these days, but they aren’t built specifically with specialty pharmacy in mind.
MaryHoa Luu-Yik at ProCare Pharmacy knows the importance of having a robust software platform designed for managing specialty workflows. “APCS is technology that allows us to document everything we do with our specialty patients,” says Luu-Yik. For example, the ProCare staff is leveraging APCS to look for trends in adherence and improvement in efficacy and quality of life. “We need to ensure that we are documenting so many elements of our patient care,” Luu-Yik says, “down to details such as whether a patient is missing doses, their emergency contacts, and the details of our financial discussions with them.” Luu-Yik also reports that they are using a calendar feature within APCS to build patient-specific task management processes. Combined, all these features mean that ProCare Pharmacy staff members have what amounts to a specialty dispensing task bar that allows them to manage and document these complex specialty programs correctly every time.
Another very important tool, according to Luu-Yik, is easy data export from APCS into reports that show, for example, when a patient has started on a medication, whether he or she is still active with it, or when the patient stopped the medication. “We couldn’t do this easily without APCS,” she says. ProCare Pharmacy also values the integration between its ScriptPro pharmacy management software and APCS, which allows for an automated flow of data such as patient and drug profiles.
Workflow is critical at Valeda Rx as well, according to Chris Antypas. He has found that success in specialty pharmacy has really come down to being organized. “You are organized when you have your technology driving the correct workflows across your specialty pharmacy processes,” explains Antypas. “So, at the intake step for a patient we have workflows configured in ScriptMed that are queuing all the various requirements that come from multiple directions for correct patient management and meeting payer requirements.” This means that staff are able to apply a consistent set of protocols for each payer and medication, for example, making a certain number of phone calls on specific topics at required intervals.
“ScriptMed affords us the ability to flag a new prescription based on these payer-specific requirements,” says Antypas. “It prompts us to add specific workflow drivers to the new referral, based on criteria such as payer and manufacturer. By setting all these drivers, or flags, on the new referral upfront, we’re able to ensure that ScriptMed will then trigger specific workflows that need to happen further down the line. So for us, ScriptMed is the ultimate organizer of different pathways to support different requirements.”
In addition, ScriptMed gives Valeda Rx staff the ability to attach multiple different statuses to a referral, with on-demand reporting, and can assign work to staff based on various statuses and sub-statuses. “These are the tools that allow us to effectively convert referrals to orders,” says Antypas, “and to report on these in a manner that’s consistent with payer, pharma, and accreditation requirements.”
Technology and Specialty Pharmacy Accreditation
There are five primary specialty pharmacy accreditation organizations. And there are a variety of different aspects to accreditation compliance that a pharmacy has to consider.
For example, explains KloudScript’s Rinku Patel, you may need to be able to provide documentation of a health history, social factors, vitals, labs, and side effects. Accrediting bodies will also look at how a pharmacy is supporting patients in navigating the financial aspect of specialty medications, such as whether the pharmacy provided prior authorization support or information on options to help the patient lower out-of-pocket costs. If a drug is not covered, accreditation will look at whether the pharmacy helps patients get access to an alternative by working with prescribers and payers. “Accrediting bodies look at a variety of data during a pharmacy on-site survey,” says Patel, “and they actually require pharmacies to report data on a regular basis, as often as quarterly.” In the end, accreditation impacts payer contracts and access to limited-distribution drugs.
There are five primary specialty pharmacy accreditation organizations. You can get more details here:
- URAC: www.urac.org/accreditation-cert/specialty-pharmacy/
- The Accreditation Commission for Health Care (ACHC): www.achc.org/pharmacy.html
- The Center for Pharmacy Practice Accreditation (CPPA): www.ashp.org/pharmacypracticeaccredit
- The National Association of Boards of Pharmacy (NABP): nabp.pharmacy/programs/accreditations-inspections/specialty-pharmacy/
- The Joint Commission (TJC): www.jointcommission.org/accreditation-and-certification/health-care-settings/pharmacy/
Well-documented, organized, and customizable specialty workflows have in fact been critical for accreditation at ProCare Pharmacy. “It takes a lot of work to be accredited and stay accredited,” says ProCare’s MaryHoa Luu-Yik. “Documenting within APCS is why we have had all the data we have needed for our original URAC accreditation and for our recent reaccreditation. We are able to easily prove that we are a viable specialty pharmacy, and we are proud of the fact that we offer our patients fully accredited specialty pharmacy services and programs.”
Technology and the Specialty Pharmacy Business Plan
Specialty pharmacy-focused software and services are not just central to patient care and accreditation, they should be central components of a specialty pharmacy business plan as well.
Here it’s important to think strategically, and recognize that though you may be cost sensitive when getting into a new business area, there is real value in bringing in the right technology sooner rather than later.
“When pharmacies are looking to get into the specialty market,” says Inovalon’s Ernie Shopes, “the volumes may not be substantial. It may be a handful of prescriptions each month. But our software can support not just a pharmacy like Valeda Rx, with its national footprint, but also what we call a specialty at retail model, in which we integrate with retail pharmacy dispensing software to give pharmacists the ability to manage specialty dispensing effectively even at low volumes.”
So, in fact, you don’t have to go all-in on software and staff to bring specialty pharmacy solutions to your practice. You might choose to start out with KloudScript’s turnkey solution that connects all aspects of starting a specialty service through the KETU platform with training services provided to bring your staff up to speed quickly, according to KloudScript’s Rinku Patel. Or you can also look to take an à la carte approach and select technology or services that may be of importance to you. “KloudScript can operate with or without an integration with other pharmacy software,” says Patel. “If there’s a small pharmacy with a low volume of specialty patients, they may choose not to pay for that integration, which usually comes with monthly fees from the pharmacy management system vendor.”
You may also want to consider how your specialty platform can drive other workflows for services your pharmacy provides, continues Patel. “With KloudScript’s platform,” she says, “you also get the capability to manage e-Care plans, non-specialty disease management programs, and value-based care programs like immunizations and point-of-care testing, if you wish to manage your patient care workflow in the KETU platform.”
Chris Antypas offers this advice, though: Don’t be shortsighted when investing in technology for your specialty pharmacy opportunities. “On our first day as a specialty pharmacy, ScriptMed seemed like it was going to be more than what we needed,” he says. “But what I heard from several colleagues in the industry is that we shouldn’t make the decision based on what we needed today, or even tomorrow. The advice was to base our decision on investing in specialty pharmacy software on where we want to be. It is a larger investment today, but that investment is significantly less expensive than having to go back and build out the technology platform once you grow to a point at which you absolutely can’t do without it. You can be sure it will be much more expensive and much more painful in the future. So we took that advice and we are very glad that we did.”
Ernie Shopes points to another interesting area that can play into business as well as clinical strategy: leveraging people’s increasing comfort level with using web portals for asynchronous, self-service interactions with their healthcare providers. “We offer ScriptMed MyShare,” says Shopes, “which is an online patient portal that allows for a self-service, personalized patient engagement. And it’s interesting to see how the pandemic has given so many people a higher comfort level with something like this. We do expect an uptick in patients wanting to engage in digital self-service models.” This can be an area then to consider, and can create what Shopes sees as a win-win. “If the patient wants self-service,” he says, “then they’re happy with the convenience and you’re taking operational costs out of the pharmacy by replacing multiple outbound phone calls to collect the same information.”
Antypas has one final piece of advice on strategy, in particular for those pharmacies that may be looking to serve specialty patients in multiple states, as Valeda Rx does. “One big reason why we wanted to have a full-featured and highly customizable specialty software platform right out of the gate,” says Antypas, “was that our strategy always called for dispensing nationwide. And we realized that, if we only had the tools to build generic, one-size-fits-all workflows, then we’d be doing countless tasks and collecting countless pieces of data that we did not need. It’s much better that we take the time up front and have the right software to build specialty programs and workflows that address the specific requirements of each state.”
Specialty Pharmacy Is Within Reach
MaryHoa Luu-Yik says that everyone at ProCare Pharmacy is very proud of the specialty services they provide for the community, and rightfully so. The pharmacy is certainly an example of how specialty is well within scope for community pharmacies. “We knew there was a need for local specialty dispensing in our community,” says Luu-Yik, “and we know that our patients appreciate the fact that we’re their local pharmacy with specialty accreditation. They appreciate and value the personal attention we can give. We can sit down with them and counsel them, in Vietnamese even if that’s what they need, and show them, in person, how to administer the medications.”
Having the right technology in place will also open doors for your specialty business, notes Chris Antypas. “Frankly,” he says, “when we talk to payers and manufacturers, just the fact that we operate on ScriptMed gives us instant credibility. They know that we have the technology to meet their requirements and then some. I do think that it’s critical to know that your software partner gives you not just capabilities, but also credibility, and we definitely leverage that every day.” CT