Improving Adherence and Outcomes in Specialty Pharmacy: A Real-World Case Study

Episode Highlights 

Q: What does an advanced clinical adherence monitoring program entail and what does the Omnicell Specialty Pharmacy Services team do to impact adherence to XIFAXAN? 

Sarah Kester: The process for our team starts at the very beginning of the lifecycle of the prescription. In a typical big box or PBM pharmacy scenario, when a prescription for XIFAXAN is received and prior authorization (PA) is needed, then the pharmacy would send that insurance rejection back to the provider and basically do nothing until they hear back from the provider that the prescription has been approved. Meanwhile, the patient languishes without their medication.

When you send your prescription to your health-system-owned pharmacy, as soon as we receive the referral and it's determined that a PA is needed, the pharmacy goes right to work on completing the PA. Our team members are very well versed in the requirements for PAs and we have a PA approval rate of over 92%.  

Once your PA is approved, then our clinical team takes over and we contact the patients. We provide them with in-depth counseling, check for any drug interactions, and educate the patient on the medication and desired outcomes for treatment.  

After the initial counseling and delivery of the medication, we continue to perform clinical follow up on a monthly basis for each patient. Seven to ten days before their refill is due, follow up calls are made to every patient. At that time, we monitor for side effects, efficacy of the medication, and any hospitalizations the patient may have experienced. We also provide monthly reminders that the patient should be on this medication for long-term maintenance and should not stop unless directed by their provider. We provide 36 months of follow up for the patient as part of our partnership with Bausch 

Q: Now Sara, what benefits do you see from this intensive follow up with patients? 

Sarah Kester: Our most important finding is the increase in days on therapy for our patients versus the national average. The average days on therapy for all XIFAXAN patients is around 5.4 months. However, patients that participate in our program are on therapy for about 9 months.  

What's the importance of a patient getting a few more months of treatment? Quite simply, it results in patients living longer, having a better quality of life, and staying out of the hospital.  

One of my favorite stories involves a patient who started on our program after being prescribed XIFAXAN after an episode of hepatic encephalopathy. This episode of HE resulted in him losing his driving privileges. When we started out, we had to speak with his caregiver because his cognitive deficit was too great for him to speak with us directly. But, after getting him established on treatment, his symptoms abated and now we're able to speak with him. He was even able to start driving again and every month he mentions that when we do our follow up. Getting his freedom to be independent back was such a great experience for him. 

Q: Let's take this up a level. Patient adherence is just one of the many challenges associated with operating a specialty pharmacy and optimizing results. Matt, what are some other common core challenges that impact specialty pharmacies and how can health systems ensure they are positioned for success? 

Matt Manning: There are a lot of considerations when it comes to launching and scaling a specialty pharmacy and we're energized to support health systems and position them for success. Let's start with manufacturer relations. Manufacturer limited drug distribution can be a huge barrier for a new specialty pharmacy. Many drugs today are distributed through a limited network of pharmacies at the discretion of the manufacturer. These drugs could be limited for a variety of different reasons — whether it's REMS considerations, storage considerations, or cost.  

I recently read that 48% of the specialty pharmacy pipeline consists of products aimed to treat orphan disease states. When you include Oncology, that number is 80%. Those are the hallmark disease states that are going to be challenging to get access to. A new specialty pharmacy will need to validate its operation, providing manufacturers with confidence that they possess the capabilities and expertise necessary to handle their drug and serve patients.  

Omnicell Specialty Pharmacy Services wants to ensure you gain access to limited distribution drugs as quickly as possible. We support this effort through our existing manufacturer relationships and SOPs. We’re able to have great conversations with manufacturers regarding their products anchored in the SOPs, policies, and programs we’ve developed to convince these drugmakers to grant LDD access to the specialty pharmacies we partner with.  

Another core consideration is access to payment networks. Again, these are limited for a variety of different reasons. Payers will restrict certain products and medications and patients to be serviced through their preferred pharmacy operation. 

We really take a unique approach to addressing the barriers of access to payer networks. Omnicell Specialty Pharmacy Services manages its own PSAO. This allows us to get into a majority of networks very quickly and allows our team to help support audits, payer relations, and negotiations.  

Another consideration is capture rate. What I mean by that is the value of medications being sent to your pharmacy. We're thinking about helping a health system build a lucrative specialty pharmacy business. From this perspective, we work with health systems to examine the different clinicians and specialties driving specialty prescriptions in their organization. We determine which of these providers and operations should be prioritized, and we measure ourselves on that. Our goal is typically a 75% prescription capture rate, meaning referrals coming into the health system-owned specialty pharmacy. This translates to savings and revenue growth for our health system partners.  

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The Future of Pharmacy Podcast is produced and distributed by Pharmacy Podcast Network. The views and opinions expressed in this podcast are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company. Assumptions made in the analysis are not reflective of the position of any entity other than the author(s). These views are always subject to change, revision, and rethinking at any time and may not be held in perpetuity.