In 2021, the American Journal of Health-System Pharmacy published a national survey of 230 health-system specialty pharmacies. According to the results of the survey, most health-system specialty pharmacies dispense less than 30,000 specialty medications in a year, maintain at least one specialty pharmacy accreditation (such as URAC or ACHC), and employ an average of 28 employees. The most concerning result of the survey was the pharmacies’ dispensing practices. Specifically, more than 68% of the respondent pharmacies do not dispense more than half of the prescriptions written by their prescribers, citing restricted access to specialty networks and limited distribution drugs as the reason they are unable to dispense more. These issues clearly continue to be among the top issues that health-system specialty pharmacies face.
Restricted Specialty Networks
PBMs continue to place onerous terms and conditions on providers seeking to access specialty pharmacy networks in order to service their patients for their specialty prescription drug products. For example, while many specialty pharmacies may focus on particular disease states, PBMs nevertheless require that the specialty pharmacy be able to service a wide range of specialty drug products across several disease states, even if they are outside of the pharmacy’s focus area. In addition, many PBMs do not always make clear what the terms and conditions are for participation, or what the scope of network participation would look like even if the provider were admitted. This makes it incredibly difficult for health-system administrators and specialty pharmacy operators to plan and prepare.
Limited Distribution Drugs
A similar and related problem for health-system pharmacies is access to limited distribution drugs. In true “Catch-22” fashion, PBMs often require that pharmacies have access to limited distribution drugs in order to gain access to their specialty networks. However, manufacturers often require providers to show network access and participation as a condition for being considered for inclusion on the panel of providers able to purchase the limited distribution drugs. Without access to such limited distribution drugs, it becomes difficult and nearly impossible for health system pharmacies to gain entry into specialty pharmacy networks. In general, limited distribution drugs are only available to a few pharmacies as manufacturers state that there is greater control and oversight by doing so. Other access requirements utilized by manufacturers include (i) national accreditations (i.e. ACHC, URAC, etc.) to demonstrate the pharmacy’s practices can handle the storage, handling, and dispensing of drug products, (ii) a highly skilled clinical team with the background and knowledge of specialty therapies and (iii) maintaining a “center of excellence” around the disease state(s) covered by the medication.
Solutions
In order for a health-system pharmacy to overcome these issues, there are several potential solutions that the pharmacy should explore. For example, as identified above, one of the access requirements for manufacturers is that the pharmacy should be a “center of excellence,” which can be initiated by several ways, including assembling case studies of positive patient outcomes for a particular disease state. To that end, health-system pharmacies should also develop robust policies and procedures for each disease state with standard reports that will later assist in specialty pharmacy applications. Importantly, health-system pharmacies should leverage any Federal and applicable State Any Willing Provider Laws, among other applicable laws, to gain entry into restrictive specialty networks.
Speak to a Frier Levitt attorney today to discuss how your hospital or health-system pharmacy can overcome these issues or any other concerns that might affect your pharmacy’s growth.
