Specialty Pharmacy: The Secret Weapon for Successful Population Health Management

Specialty pharmacies play a critical role in the success of population health management. Ultimately, the physician and the hospital are not in the middle, the patient population is. The entire site of care, site of treatment, and prescriber/pharmacist landscape engages the population throughout their health care journey.

“You can’t manage what you can’t measure,” Clelia Biamonti, PhD, senior principal at Blue Fin Group, said in a session at the Asembia Specialty Pharmacy Summit 2017. “And if we can’t measure it, we can’t understand how [to] apply the right medicine to the right patient at the right time.”

The basics of population health management involve clearly defining the patient population to be measured and successfully managed to create a singular framework. The population should be segmented into well-defined risk categories, and then develop targeted care plans according to patient risk segments.

Clinical care and risk management should be appropriately applied. Metrics need to be defined to measure outcomes and unplanned risks need to be taken into consideration. Based on these unplanned risks, care management tactics should be reassessed to provide the ability to predict outcomes and anticipate patient needs.

“The key to this is aligning incentives from end to end, from the minute the patient engages the system for an initial clinical encounter all the way to extending into the home,” Dr. Biamonti said. “Once those incentives are aligned, we know that actions follow incentives.”

Managing large and small populations typically involves data collection, aggregation, and confidentiality. Regardless of whether descriptive or inferential statistics are conducted on these populations, it boils down to looking at what proportion of the population you have.

“If there’s an exclusive relationship with a specialty pharmacy, we have a tremendous opportunity because we have almost every patient,” said Gordon Vanscoy, PharmD, CACP, MBA, and chairman of PANTHERx Specialty Pharmacy. “A tremendous numerator and denominator, which gives us a great deal of influence to be able to manage these populations appropriately. When dealing with larger populations, you may only have a small sector. You have to make sure your sampling is appropriate to do inferential statistics.”

Small population bases need a high-level of control. Furthermore, because these patients are typically devastated by their disease states, they require high-touch services, which means data needs to be highly visible. PANTHERx manages injectable ultra orphan drugs that require cold chain management. Of these drugs, many are designated for the pediatric population, and are therefore weight-based.

When managing the smart refrigerators that go out to patient homes, PANTHERx can radio tag each dose to track compliance, know what is going on, and communicate with the patient.

“There are different tools to manage these types of populations,” Dr. Vanscoy said. Orphan and ultra-orphan drugs are currently a mainstay, reinventing the management of rare diseases in specialty pharmacy, according to the panel. In 2015, the best-selling drugs were Harvoni, Humira, Enbrel, Lantus, Remicade, Prevnar 13, Rituxan, Neulasta, Revlimid, and Copaxone.

Of these top 10 selling drugs, 7 have an orphan indication, further demonstrating the tremendous growth in the orphan and rare disease market. Additionally, the economic implications for orphan drugs is not as staggering as commonly believed, according to Dr. Vanscoy.

“If you look at the total health care spend as the 100%, roughly 11% of that would be the drug spend,” he said. “Of that 11%, 29% would be the specialty drug spend, and of that 29%, only 9% of that is the orphan drug spend. So economically, these drugs are not as overwhelming as we’re hearing overplayed in the media today.”

When selecting an orphan drug channel, population size should follow the Goldilocks Principle. In other words, you don’t put 200 different patients in 200 different pharmacies because it creates a challenge managing that patient base.

“Rare disease populations are a hand-in-glove fit for the right specialty pharmacy,” Dr. Vanscoy said.

So how do we bring population health to the specialty pharmacy space? It all starts with the technology platform, according to the panelists.

“You need to make sure [the platform] can ingest data from multiple sources and then display those opportunities to the end user,” said Chronis Manolis, RPh, vice president of pharmacy and chief pharmacy officer of University of Pittsburgh Medical Center (UPMC) Insurance Services Division.

UPMC uses 5 elements: benefit design to ensure the membership is aligned and incentivized; value-based payment models to make sure incentives for primary care practices are for value-based payment models; new care models that create specialty medical homes in areas such as oncology, hemophilia, and inflammatory bowel disease; taking the same concept but bringing it to the rare diseases space; and incentives that are ever-present throughout.

To achieve this in the specialty space, technology platforms need to deliver opportunities to the physicians to act on. Currently, the landscape is moving from an episodic fee for service to population management, which means that analytic methodology needs to illuminate the opportunities.

Every 10 to 15 years a market shift in health care occurs, according to the panel. Currently, the market is shifting to the age of consumerization and value-based contracts.

“When you start seeing digital therapies, what does that mean from a pattern perspective?” said David Bennett, executive vice president of product and strategy at Orion Health. “It’s been very disease-centric, but now it’s shifting because of all the Medicare pressures on value-based contracts.”

From a pattern perspective, as proactive models of care gain prominence, technology, data, and real-time systems will grow in importance.

“Real-time systems for care management and real-time systems for consumerization because the patient has to be involved in this process,” Bennett said.

Another pattern of consumerization is personalized genomic testing, which allows a patient to find out whether they are able to metabolize certain drugs. This testing is going to affect specialty pharmacies and the health care system, according to the panel.

Therapies will change when patients are able to determine what they can and cannot metabolize or what adverse event may occur because of that specific drug. There is a vast amount of untapped data that exists outside of medical systems that could have a significant impact on our health, the panel noted.

Sixty percent come from exogenous sources, 30% from genomic sequencing, and 10% from health systems. Furthermore, 80% to 90% of health determinants are not related to health care.

As far as technology and datasets, our health care system trails far behind others, with several areas that need to be addressed. Technology needs to be evaluated in a different way in order to facilitate the collection of large-scale data, along with real-time analytic capabilities, the panel concluded.