ProxsysRx recently gathered three of its corporate executives for an in-depth discussion of how an eligible health system can optimize revenues from its 340B program and its retail pharmacy, to help build and fund an onsite specialty pharmacy. Below is a lightly-edited transcript of that discussion.
NOTE: If you’d prefer to watch the complete video of that discussion, or video segments discussing any of the individual topic areas, Click Here to visit that page on our YouTube channel.
ONE: Benefits For Patient Care
Howard Hall (ProxsysRx VP of Growth)
Why would my hospital want its own specialty pharmacy?
Heather Brooks (ProxsysRx VP of Operations & Services)
The first reason is keeping patient care within the hospital system.
1. ENSURING SYSTEM OVERSIGHT OF PATIENT CARE
When you have a specialty pharmacy on site, you can ensure that those patients are cared for appropriately. You can monitor the patients. You can make sure they actually receive the medications prescribed.
2. OVERCOMING 340B-SAVINGS RESTRICTIONS
On everybody’s horizon now, especially if you’re a 340B covered entity, are the manufacturer restrictions. When you have a pharmacy on site you get access to 340 pricing, despite the restrictions.
What does it mean for a patient to have a pharmacy where they received their care?
Lauren Robinson (ProxsysRx Pharmacy Compliance & Accreditation Manager)
If you’re getting your care at the hospital, why not also get your specialty medications right there on the campus?
3. IMPROVING PATIENT ACCESS & SATISFACTION
Your provider can send your prescriptions directly to the on-campus pharmacy. If it’s going to be covered, you already know that your benefits and financial assistance are taken care of. And then you’re right there at the door of the specialty pharmacy, in the same visit, to get your specialty meds.
Is there a benefit for the provider as well? For instance, is it helpful for a provider to know their specialty pharmacist?
It’s very beneficial.
4. BETTER PATIENT / PROVIDER RELATIONSHIPS
One of the things we do when we begin a specialty pharmacy is to build relationships with the clinic teams. We carefully choose pharmacists based on their personalities — not only for patient care, but also for integration into the clinics. And through those relationships, any issues — patient assessments, clinical monitoring, that type of thing —any issues that arise when monitoring a patient, doing an assessment, or even accessing drugs, are resolved more easily when you have those relationships with the healthcare teams.
You also have a one-on-one relationship with your pharmacist.
5. SUPPORTING CLINICAL MONITORING
You’re going to have a pharmacist with you every step of the way, making sure you know how to administer your medication — making sure you’re getting a refill when you’re supposed to. You’ll get calls once a month to make sure that you’re getting your refills filled, that you have access to your medication, and that you have a pharmacist right there, holding your hand every step of the way and going through that process with you.
TWO: Returns: Financial, Clinical
Let’s talk about returns. What kind of return can I expect from an onsite specialty pharmacy?
Specialty drugs are very expensive, and the return is very high. Especially for a 340B-covered entity.
Specialty drugs generate, on average, 600% the revenue of a retail pharmacy
What about clinical returns?
There are number of returns, and a big one that stands out is being able to partner with manufacturers who are interested in having active patients on their research medication.
Specialty drugs offer opportunities to participate in medication research
Bringing a drug to market requires a lot of research.
Specialty drugs offer opportunities to partner with manufacturers
When we have a specialty pharmacy on site, we’re able to partner with those manufacturers as we monitor and assess patient outcomes and provide data back to them that’s appropriate for their clinical trials.
THREE: The Process & Requirements
In building a specialty pharmacy, you have certain things that you need: Space. Refrigeration. Walk me through the basic qualifications you need to build one, then take me through the steps it takes to get accredited — so that you can start participating in network with some of these medicines?
It’s a long process that requires a lot of resources, a lot of effort, a lot of time.
Our role in the process of building a 340B specialty pharmacy
One of the things we do to help is we take that off your plate. We take on that initiative, putting-in our time and effort to get a 340B hospital’s specialty pharmacy off the ground.
The process is intricate but clear. We have to have the space. We have to make sure we have access to drugs. We have to make sure that we have employees and pharmacists. We get into the hospitals’ clinics and work closely with the providers to make sure that we have good relationships with them.
Meeting specialty pharmacy accreditation standards & policies
As we start to build a specialty pharmacy, we take steps towards accreditation. There are pages and pages of accreditation standards. We partner right alongside 340B hospitals to make sure that they have the policies, standards and protocols in place to ensure that their specialty pharmacy meets those accreditation standards once we raise our hands for accreditation.
How long does it typically take to obtain accreditation?
Specialty pharmacy accreditation standards & policies
It’s important to remember that you can start filling prescriptions on Day One. We work to find the prescriptions you can fill immediately, as we work towards accreditation.
Accreditation can take 6 months to a year, and it depends on the health system we’re working with — and the process of integrating into their resources.
There are steps to that you have to take before accreditation.
Specialty pharmacy accreditation timelines & steps
You have to have reporting in place. You have to fill prescriptions. So we’re filling those prescriptions Day One without accreditation, and again, it may take 6 months to a year — but you’re filling the prescriptions; you’re getting in the networks with the PBMs to be able to fill prescriptions, and then as you get the pharmacy and process stood up — and the procedures and policies in place — you’re able to become accredited.
One thing we haven’t talked about are all the things we have to measure and monitor in a specialty pharmacy, as we work towards accreditation.
When you become accredited, you have to keep certain metrics for your phone calls.
Specialty pharmacy accreditation metrics
That means there must be a body in the pharmacy every single hour it’s open. Someone answering phone calls within 30 seconds. We have to have enough pharmacy personnel in our specialty pharmacy to answer that phone.
Specialty pharmacy patient access
That means that our patients are getting immediate access to a pharmacy professional, to have their questions answered — and to make sure they’re getting the appropriate care. This goes to show how accreditation really proves that you’re a great specialty pharmacy, and that you’re taking care of your patients in the possible best way.
One of the things we can do to help with the whole process is track and measure, and then report the data back to those accrediting bodies— so the “lift” is not on the health system.
Specialty pharmacy service-data reporting
We take that responsibility off their back. In addition, there are patient monitoring and clinical assessments that have to be tracked and measured.
Every specialty pharmacy patient is monitored by a clinic pharmacist.
Clinical assessment for specialty pharmacy patients
That means, in an initial assessment, we’re asking them what medications they’re on, what side effects they’ve had — all the way down to what other medications they’re on. And then pharmacists will be working hand-in-hand with their providers, to make sure that their medication regimen is appropriate, up to date, and the most accurate regimen for the patients and their disease states.
Continuous monitoring & reporting
And then there’s monitoring. In addition to ongoing monitoring, patients are often monitored yearly by pharmacists — who review any side effects they may be having, or any issues they have taking their medication.
We ask patients if they’ve skipped any medications, and if it’s affected their disease state. The point is, patients are getting continuous monitoring by that clinic’s pharmacists. And all of that is reported back to the accrediting bodies, to make sure it’s happening — so not only are we saying it’s happening, we’re also reporting it back to the accrediting bodies.
You mentioned patient satisfaction. Answering the phone within 30-seconds, or less, is a big driver.
Ensuring patient satisfaction with their specialty pharmacy’s support
Patient satisfaction surveys are also required, and they’re required by independent third parties — to ensure that we uphold high standards. We make sure those standards are met and exceeded. We do that by carefully reviewing a specialty pharmacy’s processes. We also work closely with providers — to make sure they know what it takes to ensure that patients know we care about their outcomes, and that they have the access to the appropriate medication.
Another thing that’s particularly important in specialty pharmacy: Most, if not all, of the medications we dispense are being delivered to a patient’s door.
Specialty pharmacy shipping & packaging protocols
As we’ve mentioned, specialty pharmacy drugs are typically very expensive — and a lot of them require refrigeration. Some even have to be frozen. Some need to stay at room temperature, and can’t get too hot or too cold.
All of which is why it’s so important for specialty pharmacies to have shipping and packaging protocols required by the accrediting bodies. You have to have a Cold Chain Vendor that enables you to ship and package each medication at the appropriate temperature. We already have a network of vendors we use, and we can also vet new vendors equipped to follow approved cold chain processes — ensuring that every medication reaches a patient’s door at the appropriate temperature.
We also have processes and policies in place to test vendors’ capabilities, to make sure that whatever we’re shipping gets to patients as required.
Sounds like a lot of processes that need integration. Walk me through the technology systems you use to monitor everything — and how you integrate your operations with hospital systems.
The short answer is, when we partner with a health system, there isn’t a required To Do List for them to ensure that processes are being properly implemented — because we’re monitoring the data and implementing the processes for them.
Integrating our specialty pharmacy technology with the health system’s
We have our own technology platform in place that pulls all the data, so we can create the necessary outlooks and outputs from our analytical tools. Data we then report back, not only to the accrediting bodies, but also to the payers — the PBMs. That way, when we’re getting the specialty pharmacy in network for the patient’s PBM, we can bill for the patient’s care.
We also have to report a lot of metrics to PBMs. Everything we’ve already talked-about measuring and monitoring, we have to report to them just to get in their networks. Same thing goes for manufacturers. You also have to report to them to get access to their medications.
So there’s a lot of reporting that goes on, and we take that burden off the health system.
FOUR: Integrating Specialty Pharmacy With 340B
One of the things I like about ProxsysRx’s unique approach to specialty pharmacy is that we provide health systems with a financial “glide path,” if you will, to help fund their specialty pharmacies. A glide path that starts with optimizing their 340B network: With our 340B experience, and proprietary software platform, we help health systems optimize savings and revenue from their existing networks.
We dig deep to understand where a health system’s prescriptions are going. We evaluate the pharmacies in their networks. We get to know their providers, educating them on the best practices for working within their hospital’s 340B program. We make sure that our 340B team members work well within the health system’s culture.
We also own and/or manage retail pharmacies for dozens of health systems, and we’ve developed processes for setting-aside retail-pharmacy revenue to fund specialty pharmacies. We capitalize on the increased revenue we generate with our Meds To Beds program. We help health systems increase the number of their employees getting prescriptions from their retail pharmacies.
We optimize opportunities for a hospital’s clinics to affordably fill their patients’ prescriptions with the hospital’s retail pharmacy. All of that is part of our unique approach.
We’ve proven that ProxsysRx can help health systems drive new and better revenues while their specialty pharmacies are being built; often, that’s literally millions of dollars in new revenue for a health system. More importantly, we’re doing this while we’re helping hospitals improve the quality of care they’re providing patients. And again, at the same time, we’re helping them cover the costs of building their specialty pharmacies.
We’re currently in the process of doing just that for a major Southeastern health system, and they are really excited about the program we’ve implemented.
The response from one health system
Generally speaking, they’ve been very supportive in working with us to analyze their 340B program — looking at any and every opportunity to optimize their 340B savings and revenue.
There are so many ways to optimize a 340B program, while — at the same time —making it more compliant. And it’s changing all the time, so we’re always looking to ensure that we’re capturing everything coming out a health system.
The people at this particular health system have been wonderful to work with; they’re really excited about the growth potential of their 340B program. They’re excited about seeing more 340B savings going back into their health system, and the positive impact that’s going to have on their ability to take care of their patients. And yes, they’re excited to see some of those savings being reinvested into building their specialty pharmacy — for which, there has been tons of support.
Getting paid more for doing better by their patients. I love it.
I’ve spent a lot of time building a solid working relationship with one of the main leaders at the health system.
Working with health system leadership
She’s been my go-to person for answers, when we need information from them — and we’ve been helping her understand what it takes to be a leader in specialty pharmacy.
I’ve worked in a large health system myself, and I know how hard it can be — in that position —to trust people and companies outside the system. So a big part of my job in building our relationship has been building trust and that communication. That’s been a really rewarding part of my job, helping lay the foundation for something that’s going to be successful in the future.
You come from a major academic medical center. What lessons did you learn from that experience that you’re applying now to help drive this?
Communication is critical. There are a lot of different avenues to communicate, and one of the things we’ve had to deal with, since Covid, is working virtually. And you know what? Establishing trust is a lot more difficult when you can’t meet in-person. So one of the main things I’ve tried to do is increase my one-on-one time with the leaders I’m working-with at the hospital — to make sure that we’re on the same page, and to make sure that we — and they — are asking questions that need to be asked.
Building client trust and self-confidence
It really is a process of breaking-down barriers and instilling confidence in the people I serve. I want to make sure they’re comfortable coming to me when they don’t know something. So a big part of what I’m doing is helping build-up those leaders’ confidence in what they’re doing from their end. After all, they’ve never had a specialty pharmacy before.
That’s where we come in, providing not only answers but the confidence they need — to not only start and open their specialty pharmacy, but looking ahead to managing a successful pharmacy in the future.
FIVE: Avoiding Negative Specialty Pharmacy 340B Reimbursements
How does a hospital get upside down in specialty pharmacy? What causes negative reimbursement?
That’s a great question.
#1 Overlooking 340B dispense status
One of the easiest ways is not paying attention to the 340B status of a particular dispense. Especially if you’re a Disproportionate Share Hospital — a DSH hospital, you’re subject to the GPO prohibition.
Purchasing drugs at WAC instead of on 340B account
As such, you would be hit with purchasing the drug at WAC (Wholesale Acquisition Cost), rather than on the 340B account, if it doesn’t qualify. That’s another way we partner with health systems. We make sure that every prescription that should be eligible is deemed eligible in the processor, so that they’re not upside down in the pharmacy dispense.
So what do you do if you get sent a drug and you don’t have access to that PBM yet? How do you handle that?
You really don’t want that to happen because it means you’ll need to send a patient somewhere else to fill their prescription.
Receiving 340B specialty pharmacy drugs without PBM access
That can happen, but one of the things we do is to make sure, when we go into a specialty pharmacy project for a health system, is understand who the payers are in that community — so that we can address it on the front end, and get access to that network. We work through that, navigating through all the reporting requirements beforehand.
Accessing a 340B hospital’s payor network
We make sure all of it gets done, because our goal is to enable the 340B health systems we serve to take care of every patient
Talk to me about getting prior authorizations, assuming most of these drugs require prior authorization. How much time is spent doing that, and what’s the burden on a facility to do that?
One thing about specialty pharmacy medication is that it’s so expensive.
Overcoming 340B PBM / payor hurdles
Many PBMs will not pay for prescriptions right out of the gate, so there are a lot of hurdles you have to get through with the payor to get drugs covered. Even after a 340B specialty drug is covered, the copay can be very high — sometimes thousands of dollars.
Securing copay assistance for specialty drugs
Most patients can’t afford copays that high, so what we do is search for copay assistance. There are manufacturer programs, and other assistance programs — including charity care. We search among all those options to make sure that a patient can get a prescription within a few days. It’s usually two-day turnaround, and then the drug is on its way to the patient.
That’s another benefit of having a pharmacist embedded in the clinic where the patients are, because the pharmacist in that clinic is able to provide that assistance before they even get to the specialty pharmacy.
Performing prior authorizations for specialty drugs
They’re able to look for financial assistance. They’re able to perform those prior authorizations, making sure that prescriptions are going to be paid for, and that patients can afford them.
Before the patient gets to the specialty pharmacy, there’s been a conversation with the pharmacist dispensing the drug. It’s already taken care of, so once it gets to the specialty pharmacy, we’re going to be able to fill it because we’ve done all of that on the front end in the clinic, and in the clinic setting.
I’m assuming from the patient there’s no surprise bill.
Communicating with 340B patients about their specialty medications
They understand how this is going to get paid. And we know that the people taking specialty drugs are generally your sickest patients. In general, that’s what specialty drugs are for: People with cancer, MS, etc. We don’t want them worry about their bills.
SIX: The Retail / Specialty Pharmacy Relationship
Talk to me about the relationship between retail pharmacy and specialty pharmacy. What advantages or efficiencies are gained by having both of them in a system, including coordination between the two?
When you have both a retail and a specialty pharmacy onsite, then you can ensure that the entirety of the patient prescription care needs are met.
Meeting all of a patient’s medication needs
Very often, patients have prescriptions from both a hospital’s retail pharmacy and its specialty pharmacy. We can ensure that those patients get both prescriptions. We can ensure that there are no delays on either. We make sure each team knows what the other is doing, as far as providing for those patients — even to the point of combining prescriptions in single shipments, getting all of a patient’s medications to them at one time.
So in hospitals where we have retail pharmacies and specialty pharmacies, can a patient call the retail pharmacy with questions and get answers about specialty drugs?
Yes you could.
Addressing 340B patient questions about their specialty medications
At either place, you’re going to be talking with a pharmacist who has the education needed to answer most of the questions. But when it comes down to anything clinical about patient monitoring, or anything that has to do with the really high complexity meds, then a patient would be connected with one of our clinical pharmacists for their disease state — because those pharmacists have the in-depth training and certifications needed to address the patient’s questions.
We also ensure patients speak to our clinical pharmacists before each refill, which gives the clinical pharmacists the opportunity to answer patient questions or concerns — and check for medication effectiveness and side effects.
SEVEN: Why choose ProxsysRx for your hospital’s specialty pharmacy?
Specialty pharmacies are important part of the pharmaceutical ecosystem.
Creating a financial glide-path to fund your specialty pharmacy
At ProxsysRx, we help health systems create a financial glide path to building them. A path that ensures the burden of financing the specialty pharmacy is of little to no risk to the health system.
We take responsibility for ensuring that everything is done correctly from beginning to end. Which means that the hospitals we serve can rest assured that that it’s in good hands, and they don’t have to spend extra time, or energy, or effort worrying about whether or not their sickest patients are going to be seen.
Opening a specialty pharmacy is incredibly challenging, and we take that burden off of the health system. We’re the experts who walk them through, navigating them through the process of getting a specialty pharmacy up, running and successful. We handle meeting the accreditation requirements. We get them access to the medications they need. We get them access to the payors. We take responsibility for integrating their specialty pharmacy with their clinic teams. Then we take-on everything that’s required to really grow the specialty pharmacy on site.
We get to know your doctors, your clinicians, and your patients — so that we can tailor your specialty pharmacy’s services and medications to the needs of your patients, and the difficult disease states that your health system needs to manage.
ProxsysRx is here to help, if you have questions.
For more information on how to build and fund a successful specialty pharmacy, or for more information on any of the pharmacy-support services we offer, contact Howard Hall. C: 214.808.2700 | firstname.lastname@example.org