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The High-Touch Challenge

While specialty drugs have been available for several decades, the rapid growth in both the quantity and cost of these drugs over the last few years has put specialty drug therapies in the spotlight.

As specialty drugs increase in prevalence, the specialty pharmacy may turn out to be at the very center of the accountable care movement. New reimbursement models tied to improving outcomes are emerging, and these may help to offset the continual decline in pharmacy margins.
However, accountable care organizations and insurers focused on the cost and performance of specialty drugs expect pharmacies to deliver high-touch services that deliver positive outcomes. While many specialty pharmacies are eager to attract new business, providing cost-effective services that meet increased expectations for patient care is a challenge.

Continue @ Specialty Pharmacy Times >>

While medication adherence has always been a challenge, it hasn’t been financially painful enough for patients or stakeholders in the healthcare industry to seriously try and improve.

Thanks to the move to value-based healthcare, a “not my problem” attitude is changing fast. Medication non-adherence costs billions. It costs almost $300 billion in avoidable medical spending — billions that payers can ill afford.

It costs billions to pharmaceutical companies in lost business and it is now costing health care providers penalties, potentially in the billions, for not achieving accountable outcomes, such as hospital readmission rates, physician quality reporting system (PQRS) measures, or effects of the plans’ star ratings under Medicare.

Currently, financial pain is experienced in two primary areas; hospital readmission rates, and 5-star ratings.

The Affordablmedicare-measures-for-chronic-conditionse Care Act (ACA) requires the Centers for Medicare & Medicaid Services (CMS) to impose penalties on hospitals whose readmission rates for heart failure, heart attack, and pneumonia are worse than the national average. With nearly one in five Medicare patients returning to the hospital within 30 days, many institutions could improve their readmission rates through improvement in their patients’ adherence to treatments recommended at discharge.

The second area of financial pain is for Medicare Advantage plans where bonuses worth several millions are tied to their CMS 5-Star rating. The rating is based on 50+ measures, with many of the most highly weighted are tied to medication adherence in chronic conditions such as diabetes, high blood pressure, and hypercholesterolemia.

 

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