Pharmacy

Study finds health system specialty pharmacies linked to reduced cost of care for MA patients

A study published in the Journal of Managed Care + Specialty Pharmacy found Medicare Advantage patients reduced their cost of care by using specialty pharmacies instead of mail order or retail pharmacies.

By Emma Bardin on May 03, 2022

A new study published in the Journal of Managed Care + Specialty Pharmacy found a correlation between health system specialty pharmacies and reduced cost of care for Medicare Advantage patients when compared to cost of care associated with mail order or retail pharmacies.

The study defines a health system specialty pharmacy as one that functions within the health system itself. Such pharmacies assist with care coordination such that  the care team can oversee every aspect of the patient’s care.

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Health system specialty pharmacies are also associated with improved patient outcomes, according to the study. The study looked at data from specialty pharmacy patients of Shield Health Solutions, a specialty pharmacy accelerator that aims to increase drug access for specialty pharmacies. Shields Health Solutions —based in Stoughton, Massachusetts — funded the study. 

“This study looked across Shields partners specifically, and their care model impact on total cost of care,” said Stephen West, chief strategy officer at Shields, in an email. “Shields partners have embedded personnel in specialty clinics (work in the same EMR and often in the clinic physically).”

“[Shields has] deep and broad collaboration within health systems and across health systems to deliver clinical quality for highly diverse and complex disease states,” said Dale Fasching, regional director of clinical operations at Shields, in an email.

Specifically, the retrospective cohort study drew on Medicare Advantage beneficiaries’ pharmacy and medical claims data from 2018 and 2019. The study looked at information from 9,780 members, 208 (2.1%) of whom utilized services from health system specialty pharmacies to see if one side had a monetary advantage over the other.

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Of note, the costs for health system specialty pharmacies versus retail and mail order ones were comparable in 2018, according to the study. However, in 2019, health system specialty pharmacies were associated with a reduced cost of care for Medicare Advantage patients, the study said. For example, health care plans paid closer to $7,000 per member per month for health system specialty pharmacy users, while health plans paid $7,600-$8,100 per member per month for those in the provider benchmark groups and network benchmark groups; that number reflects the total cost of care – including medical and pharmacy costs — a health plan plays per member per month.

The study attributed the disparity in cost to two factors: savings in pharmacy and free-standing physician-related costs.

“We believe this study will help inform how integrated health system specialty programs can take risk with payors to expand the patients they serve. These studies have helped our partner’s at UMASS expand their Medicare Advantage plan, and we believe that this type of evidence can help inform other health system partners how to take risk incorporating specialty pharmacy patient populations in a similar way,” West said.

West and Fasching see opportunity to expand upon the study’s findings, too.

“[Next steps needed include demonstrating] the same results for more patients, and [diving] deeper into specific patient types (by therapeutic or specialty condition). Patient engagements, often enabled through technology and embedded personnel in health systems, allow for care quality impacting clinical interventions by pharmacy teams,” Fasching said. “There is a rich connection between where value comes from in various patient sub-groups and how patient engagements/interventions within health systems arrive at that value. We have studied many of these connections will continue to publish and share.”

Photo: Ridofranz, Getty Images