The Growing Role of the Health-System Specialty Pharmacy

Surrounded by the hustle and bustle of New York City is the headquarters of NYU Langone Health, one of the nation’s premier academic medical centers. Outside of this location, NYU Langone maintains more than 230 sites across the New York, New Jersey, Connecticut tristate area.

Navigating the health care landscape at that scale is challenging, but nevertheless NYU Langone has earned a reputation as one of the nation’s top providers of specialty pharmacy services. Ameet

Wattamwar, PharmD, assistant director of pharmacy at NYU Langone, who recently spoke at the CBI’s summit regarding drug manufacturers partnering with integrated delivery networks for limited distribution drug access, has been championing health-system-owned specialty pharmacy since studying its positive effect on patient outcomes.

We spoke with Wattamwar regarding his experiences setting up NYU Langone’s specialty pharmacy and the health system’s plan for covering more patients with the pharmacy’s enhanced care services. He discusses the practical challenges, surprises, and benefits for patient care, including lessons every director of pharmacy should know before starting or expanding a health system’s specialty pharmacy.

Can you begin by telling us how your specialty pharmacy program started?

Wattamwar: We turned the lights on as a specialty pharmacy on July 31, 2017. But we didn’t really have significant payer contracts until October 2017, so our pharmacy has been fully operational since then.

When we first planned the program, we focused first on where we could make the biggest impact for patients. We knew we couldn’t jump in immediately at all 230 sites, so we developed a strategy to figure out exactly how we could start and where we could add the most value as fast as possible.

To get the program off the ground, we decided to partner with a specialty pharmacy integrator and accelerator because we wanted to leverage the success that they had setting up specialty pharmacies for other health systems. Specifically, we wanted to leverage the infrastructure they already had in place to help us accelerate our entry into the market. We started with 10 clinics, including oncology, transplant, dermatology, rheumatology, pediatrics, as well as a number of other practices.

Currently, the NYU Langone specialty pharmacy is servicing close to 20 unique departments that are dispersed across Manhattan, Long Island, and Brooklyn. We are going to continue growing as quickly as we can until we are eventually able to support all patients who are seen by specialists throughout the entire NYU Langone health system.

How is your specialty pharmacy program structured differently from a contract or external pharmacy?

Wattamwar: Our specialty pharmacy program is broken down into three distinct functional groups. They all work together as one team to support both our patients and our providers. The three buckets are:

• Pharmacy Liaisons

Pharmacy Liaisons are pharmacy employees who are embedded within specialty clinics and are responsible for a number of different things, including all prior authorization and patient financial assistance. At a high level, the liaison’s primary job is to make sure that patients get started on specialty therapy quickly and efficiently, which is a really difficult process. What we found at NYU Langone, and I think you would find this across the board at most health systems, was that tedious prior authorization paperwork was being done by nurse practitioners or nurses and, in some cases, the physician. This paperwork was very labor intensive and took up so much time that nurses and physicians weren’t able to serve as many patients as they wanted or spend as much time with patients as they wanted. Today, liaisons in each clinic, supported by a centralized team of subject matter experts, complete all of that paperwork for the care team, which frees up time for the care teams to practice at the top of their licenses and spend more time directly with patients.

• Dispensing Pharmacy

The second bucket is our dispensing pharmacy. While it will look and feel like most dispensing sites, I would say that one of the most unique attributes of this dispensing site is the fact that we’re all using one shared (electronic medical record [EMR]). So, if the prescriber in the clinic writes a progress note or any pertinent patient information, our clinical pharmacist team has access to that information. This way, they can ensure that a prescribed medication is appropriate for the patient from a clinical standpoint. Our pharmacy team can do things that external pharmacies just aren’t able to do without access to the EMR. Because we are all NYU Langone employees, it’s a lot easier to communicate and we typically see prescriptions reaching patients much faster as a result.

• Centralized Clinical Pharmacy Team

The third bucket that really makes this program incredibly unique is our off-site, centralized team of clinical pharmacists, which is right now being operated by our integration partner, Shields Health Solutions. We are all just one team working together. Our clinical pharmacists actually call the patient, onboard them into our specialty pharmacy program, and develop a relationship with the patient.

Using data collected by this team, we use analytics systems to assess patient risk and figure out exactly what level of engagement we need to have with every single patient. So, at a minimum, our clinical pharmacists will call every single patient once a month before it’s time for their refill to do an adherence check. To me, that makes all the difference in the world. That really allows the health system to extend itself into the patient’s home, whereas in the old model, we really wouldn’t know what was going on with the patient and whether they even received their medication until their follow-up appointment. Today, in real time, we know exactly what’s going on with the patient. That right there is unprecedented in terms of a provider’s ability to continuously track her or his patients’ progress.

What were some of the barriers you faced and how did your approach help alleviate those challenges?

Wattamwar: Our primary objective was figuring out how we could get into the specialty market as quickly and effectively as possible. We wanted to provide consistent and reliable service at the highest possible standard of care. Shields was really instrumental in helping us do that.

As I mentioned earlier, they provided critical infrastructure elements that are now core components of our program. For example, for us to have a centralized clinical pharmacy call center we would have to first find the real estate, then hire and train the team. That alone could have potentially taken years from the start until we were able to actually execute. But, because our partner already had that infrastructure in place, it was really easy for them to turn the lights on and provide that service for us until we are able to develop the capability to do that on our own.

Q: What metrics are you using to monitor successes and patient outcomes?

AW: Something we tracked from day one was prior authorization (Pas) turnaround time. Since our liaisons started completing prior authorizations in clinic, we are seeing 50% to 60% of our PAs being completed within 24 hours and over 75% completed in 48 hours. That is great for a number of reasons, but most importantly, it ensures that you’re getting your patient on their therapy as fast as possible.

Another metric we measure is the total financial assistance secured for patients. In one year, we’ve secured $17 million worth of financial assistance for NYU Langone patients. If we hadn’t been providing this service, the number of patients who would’ve fallen through the cracks would’ve been very high. How many of these patients wouldn’t have been able to afford their therapy, and as a result, wouldn’t have received their therapy? That right there is something we are so incredibly proud of.

We also track total interventions made by our clinical pharmacy team. We track interventions across all of our therapeutic areas, but in oncology specifically, we found that over the last 12 months, we have made more than 132 clinical interventions directly as a result of conversations that a pharmacy representative has had with the patient.

Also, across every one of our therapeutic areas, our patient days covered (PDC) rate is now above 90%. This is an important metric to track and a tool we are now using to begin predicting patient medication adherence.

Wattamwar: I think it’s most important for people to understand the role that the health system can play in providing specialty pharmacy services and the true value that they can provide patients and providers when compared to national specialty pharmacy chains.

I usually like to give the example of a transplant patient. In the old model, you might have a patient who received a liver transplant and is being cared for by the best medical team in the world. But, when the physician gives the patient 14 different prescriptions after his transplant, all he can do is hope that the patient can afford all of the medications and he actually takes them. If the patient doesn’t, his new organ will likely be rejected and he may end up in the emergency room a few weeks later.

So, our providers can do all of the best clinical work imaginable, but it’s like carrying the football all the way to the 10-yard line and then being forced to walk away and let someone else take the football into the end zone. Now, with a specialty pharmacy that we fully own and control, we can continue to track that patient for as long as necessary to ensure they receive the care they need. It really allows us to close the loop and provide the full continuum of care for our patients, which is of the upmost importance for our health system as a whole.