New pharmacy models and healthcare data needs are beginning to emerge from the macro changes occurring in US healthcare. Healthcare reform has accelerated the drive to create new care delivery and payment models. Specialty drugs are rapidly increasing their proportion of the overall US drug spend. Taken together, these trends are forcing new alignments in how manufacturers interact with the healthcare system, creating both opportunities and significant challenges with regard to healthcare data solutions.
Emerging pharmacy models
Providers are being driven to consolidate, integrate and coordinate the continuum of patient care in order to enable accountability for outcomes, cost and quality of care. This is having a direct impact on use of medicines. The traditional practice—“tossing prescriptions over the wall”—into wide-open pharmacy does not support accountability for outcomes, cost and quality of care. Dispensing and use of medicines must be part of the patient care consolidation, integration and coordination that is occurring within integrated networks (IDNs/IHNs) and accountable care organizations (ACOs). Three integrated pharmacy models are already emerging to accomplish this:
- A complete pharmacy model that is owned and/or controlled by the System/IDN/IHN/ACO, including brick-and-mortar community pharmacy, mail-service pharmacy, specialty pharmacy, home infusion, infusion suites and even patient services
- A medication therapy management (MTM) function that is owned by the System/IDN/IHN/ACO, which manages dispensing and utilization within a preferred network of pharmacies
- “Poly-pharmacy” outsourced by the System/IDN/IHN/ACO to a third party (e.g. CVS Caremark or Walgreens) that has retail pharmacy, mail-service pharmacy, specialty pharmacy, infusion suites, home infusion and patient services
These pharmacy models are emerging initially for specialty drugs because they are often associated with high-cost and high-risk disease states. These models also emerge when the provider motivation is optimized patient care or maximized revenue. The important success factors for these pharmacy models are integration into the overall continuum of care, influence on the patient experience and access to key drugs. In turn, this is creating a new and powerful lever for gaining access to manufacturer’s drugs that are in limited pharmacy networks. Coordination along the continuum of care refers to creation of and adherence to standards of care and clinical pathways. Integrated pharmacy models will have specific requirements and expectations for economical access to the drugs that are part of their standards of care and clinical pathways. Not too dissimilar from formulary control, this will create a new lever used to gain access to limited pharmacy networks and to influence product acquisition economics.
The emerging integrated pharmacy models will require manufacturers to be flexible and agile with their channel configurations and networks, and will create the need for greater visibility and measurement of pharmacy performance.
Measures of pharmacy performance
A manufacturer’s revenue is directly related to Time to Fill, Medication Possession Ratio (MPR) and Time on Therapy (see definitions at right). Initiating patients quickly on therapy, eliminating gap days between fills and keeping patients on therapy longer all contribute to maximum revenue per patient. As specialty drugs become more common, these measurements of prescription efficiency receive greater attention.
Time to Fill, MPR and Time on Therapy also impact the overall cost of care, quality of care and patient outcomes, especially for specialty drugs. If a prescriber has made a decision that use of a certain drug by a patient is clinically necessary, then optimizing these three factors, aligned with the prescriber’s written regimen, is critical to achieve the desired outcome. Specialty drugs often have many more potential barriers in these areas than a traditional small-molecule drug.
Measurement of prescription efficiency has the potential to support the ongoing drive for increased visibility, performance measurement and accountability. For at least the past 10 years the idea of outcomes-based contracting between a manufacturer and a payer has been terribly slow to gain traction and is still a far-off vision for many manufacturers and disease states.
Could prescription efficiency be a proxy for outcomes? Could prescription efficiency, instead of measured outcomes, underpin drug manufacturer-payer risk-sharing and response-rebate models?
Sophistication for measurement of prescription efficiency, i.e. Time to Fill, MPR and Time on Therapy, requires expanded healthcare solutions such as data management and analysis capabilities for manufacturers and their data service providers. Specialty drugs are ideal for establishing these capabilities as the scope of data availability is far greater today than for traditional small-molecule drugs.
Effect of prescription efficiency on revenue per patient. ‘Prescription efficiency’ combines time-to-fill, medication possession ratio and time-on-therapy. This scenario is for a $60,000/yr drug.
Implications for Specialty Data Management
If managing data for a limited network of 15–20 specialty pharmacies is challenging today, consider how that will be impacted with another 15–20 IDN/IHN SPPs and ACO SPPs as part of that network. If finding relevant and actionable data is difficult today for Time to Fill, MPR and Time on Therapy, consider how that will change when contract performance and payment tiers are on the line. So what does this mean for specialty data management?
Manufacturers will need smart data requirements that are directly linked to thorough data management and business-utilization use cases. They will need to know which data elements are necessary for support of critical business processes. This enables manufacturers to “right-size” the data that they pursue from their pharmacies and the data support services that they require for data management.
Manufacturers will need to broaden their data scope beyond just dispense data to also include prescription statuses. Statuses such as Pending, Denied, Hold, Cancelled and Discontinued are critical for ensuring that Time to Fill, MPR and Time on Therapy measurement results are relevant and actionable. There are many valid reasons for a prescription delay or stoppage, and they sometimes need to be identified and filtered out of the prescription efficiency measurements. These statuses also ensure accurate tracking of when patients are active vs. closed, which is fundamental for measurement of MPR and Time on Therapy.
Manufacturers will need to ensure patient longitudinal integrity while also staying compliant with privacy and security requirements. This could mean shifting the definition of data intermediaries to become pharmacy business associates and changing the location of where de-identification algorithms are applied in the overall data flow to enable more diverse pharmacies with very different data capabilities to participate in limited pharmacy networks.
Manufacturers of specialty drugs have significantly evolved their specialty channel and data management capabilities in recent years, and this evolution will need to continue as the rate of change in US healthcare increases. New pharmacy models, prescription efficiency analytical sophistication and expanded data management requirements will require manufacturers to be flexible and adaptable in their management of specialty channels and data.
ABOUT THE AUTHORS
Marc Duey is President of ProMetrics, LLC King of Prussia, PA; firstname.lastname@example.org. Jason Bogroff is principal consultant, Blue Fin Group, an Atlanta-based consulting firm.