Rare Disease Pharmacy Insights

The world of specialty pharmacy billing is set to undergo significant transformations driven by biosimilars, pricing transparency, value-based contracting, and the integration of pharmacy and medical claims. Biosimilars promise cost savings, modifying billing practices by necessitating billing under distinct benefits and demanding updated billing guidelines. Transparent pricing is becoming crucial due to the scrutiny of Pharmacy Benefit Managers (PBMs), leading to fewer errors and streamlined claims processing. Meanwhile, value-based contracting shifts focus from volume to quality, requiring pharmacies to adjust billing processes to reflect service performance over quantity.

Furthermore, integrating medical and pharmacy claims can transform operational efficiency and patient care. By providing comprehensive patient data, this integration ensures billing accuracy and reduces errors, blending the best of medical and pharmacy claims into a cohesive system. As these trends evolve, specialty pharmacies must adapt promptly, or risk falling behind, emphasising the need for outsourced billing services. Engaging with a trusted Revenue Cycle Management (RCM) company can help navigate these complex changes, ensuring financial health and patient satisfaction are optimised without the administrative burden.

The Integrated Specialty Pharmacy Model boosts patient health within large health systems, stressing coordination for improved outcomes. HOSP advocates this model, addressing challenges like pharmacy 'deserts' and high prescription abandonment rates. HOSP President Tim Affeldt highlights the model’s focus on patient wellbeing over profit, ensuring seamless medication access and reducing hospital visits. While aligning member health systems, HOSP's committees focus on demonstrating the model’s value, engaging in advocacy, and sharing best practices.

HOSP also opens partner memberships to stakeholders like drug manufacturers and wholesale distributors to foster equitable access to affordable medications. Among challenges, protecting system-owned pharmacies from losing savings generated by 340B discounts is crucial. This allows them to support underserved communities. Despite differences, pharmaceutical companies within HOSP enable discussions on common industry ground.

A recent report highlights the integral role of specialty pharmacies in delivering complex therapies and supporting patients through adherence programmes and financial assistance. The study benchmarks pharmaceutical manufacturers’ engagement strategies, assessing business productivity and relationship management with these pharmacies. Notably, manufacturers that demonstrate operational alignment and data transparency earn higher scores, while mismatched patient support programmes cause friction. Critically, industry-wide benchmarks emerge as catalytic, driving manufacturers towards improved strategies.

Enhancing these partnerships can streamline patient journeys and outcomes. Recommendations include aligning operational practices, enhancing data exchanges, fostering collaborative relationships, and embracing ongoing benchmarking efforts. This approach can refine engagement strategies, benefiting both pharmacy operations and patient care, leading to significant industry advances.