Promoting collaboration between payers and specialty pharmacies

Perspective: Connected care | Capability: Pharmacy | By: Carelon

Collaborative healthcare is important in any setting, but even more so when supporting patients with complex or chronic illnesses. The management and administration of life-saving or quality-of-life medications for these patients demands integration between payers and specialty pharmacies.

Here, CarelonRx describes how the combined expertise of payers and specialty pharmacies can help bridge gaps in care, optimize patient experiences, and foster a more connected healthcare system.


What unique skill sets do payers and specialty pharmacies bring to the table?


Both payers and specialty pharmacies have unique skill sets, resources, and leading experts that, when combined, can help reduce care gaps and improve patient outcomes. Payers are able to drive cost management and offer compliance assistance and specialty therapy guidance. Payers' teams of pharmacists and pharmacy technicians are available 24/7 to answer members' questions and provide customized outreach to assist with medication management and adherence. Payers also have a direct influence over their networks, identifying and incentivizing value-based care providers, whether that be a pharmacy provider or a medical provider. That's important, because we want patients to go to those highest-quality, most cost-effective providers.

On the other side, specialty pharmacies provide additional access to skilled pharmacists and pharmacy technicians, as well as physician consultations to improve management of adherence and adverse effects. They also dispense 99.98% of prescriptions with zero errors, and distribute 99.91% of prescriptions with no errors .

How can payers and specialty pharmacies positively impact patients through collaboration?

Payers and specialty pharmacies can start by taking a consumer-centered health approach. This places people at the center and allows for the connection and sharing of information to support patients and members wherever they are in their health journey. It's the idea of promoting whole health and connected care, rather than a disjointed system.

When payers and specialty pharmacies work together in this way, they are able to combine their technology and clinical expertise to create a holistic view of a patient's medical and pharmacy needs. This collaboration allows for visibility into a patient's pharmacy claims, their complete medication list, health outcomes, and barriers to care. The integration of this information enables providers, pharmacies, and payers to make coordinated care decisions that help prevent adverse medication interactions, increase medication adherence, bring down healthcare costs, and ultimately improve quality of care.

Infusion therapy is a key example. Infusions cost three times more in a hospital compared to an ambulatory care setting. CarelonRx aims to work together with payers to ensure benefit designs encourage patients to be aware of these differences in their benefits. Then, our care teams can educate patients and direct them to the optimal places in their community where they can receive that benefit, at a lower cost, while still seeing an equal, if not better, health outcome.

Through collaboration, payers and specialty pharmacies can partner to deliver need-based support, provide clinical interventions, monitor therapies of each patient, expedite time to therapy, produce real-time reporting on the patient journey, and increase medication adherence for those who rely on them most.


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