Page 21 - 2017 V1 InsideOut

specialists are involved, which means additional locations and diagnostics and record transferals and maintenance, all of which duplicate and increase admin- istrative functions but do not necessarily contribute to better patient outcomes. Additionally, federal laws such as The Stark Law and The Anti-Kickback Statute prohibit physicians from engaging in “self-referrals” to entities where the physi- cian or an immediate family member has a direct or indirect nancial relationship.
Health systems have all of the necessary providers under one roof, they maintain all of the patient records in one location and can better coordinate increasingly complex care, which makes the patient experience better, and improved patient outcomes should translate to increased reimbursement rates.
Biggest Challenge for Health Systems
Strategically speaking, health systems are not hedging their bets on any one strategy right now. In addition to purchasing phy- sician practices and local competitive health systems, many are also trying to aggregate themselves into clinical groups and achieve differentiated reimbursement. Health systems are also looking to start
up their own specialty pharmacies—and that’s one of their biggest challenges. They would love to offer all of the specialty pharmaceuticals, but the market dynam- ics work against them due to multiple complexities.
Payers and manufacturers understand these complexities and, to keep the process simple, contract with a limited number of specialty pharmacies.
Payers use cost-controls as incentives, with the long-term arch leading to better patient care. Regardless of who supplies the pharmaceuticals, payers still cover the same amount of patients — or covered lives — but if they’re covering patients from every healthcare provider, indepen- dent specialty pharmacy and physician dispenser, the complexities go through
the roof. Payers recognize, for example, that few providers commonly treat rare diseases, so claims for specialty phar- maceuticals will likely be billed wrong and overall administrative costs will in- crease. Payers keep the process simple by contracting with high-volume users, such as specialty mail order pharmacies and pharmacy bene t managers.
The same scenario applies to manufac- turers. Manufacturers could open their specialty products to all pharmacy types, but they understand the nuances and complexities involved with these life- sustaining medicines. Similar to payers, manufacturers recognize that high- volume specialty pharmacies cover the majority of patients, and even though it narrows provider access, manufacturers still supply specialty pharmaceuticals to the majority of patients and in the fewest possible moves.
Yet, regardless of who dispenses the specialty pharmaceutical, health system pharmacists are doing all of the work in managing patient care. Pharmacists know what side effects a patient may experience on a therapeutic, understand the patient may be reluctant to take a medicine,
and recognize how drugs interact and how those interactions can be managed successfully. Health systems, however, are not getting compensated for this level of patient-centric care, and we’re hoping to facilitate their access to specialty therapies to offset the case management cost.
About the author
Matt Johnson joined ASD Healthcare in June 2012 as Chief Operating Of cer after serving seven years as Vice President of Strategy at AmerisourceBergen Specialty Group. With more than a decade of experience in the specialty pharmaceutical business, his areas of expertise include strategic planning, informatics and technology. He holds a bachelor’s degree in mechanical engineering from Northwestern University, a master’s in mechanical engineering from California Institute of Technology and a master’s in business administration from Auburn University.
Solution from ASD Healthcare
Our goal is to help health systems gain access to provider administered specialty pharmaceuticals and help them get better pricing. Because of our expertise with specialty pharmaceu- ticals, ASD Healthcare is in a unique position to do that.
We have gathered a small group of health system providers who are on the cutting edge of care and we are acting as a conduit between them and our manufacturing partners, so providers can address patient-centered issues directly to manufacturers, and manufacturers can gain insight on factors excluded from their overall processes. We’ll be featur- ing more on this model in a future issue of InsideOut.
ASD Healthcare | 17