The prevalence of specialty pharmacy networks is increasing and in the coming years will threaten the existence of the “buy-and-bill” model that currently guides many physician drug-purchasing habits. Will you be ready?
According to Roderic Bryant, the prevalence of specialty pharmacy networks is increasing and in the coming years will threaten the existence of the “buy-and-bill” model that currently guides many physician drug-purchasing habits.
David Suchanek, RPh writes that the rise of specialty pharmacies came in response to “pharmaceutical and biologic products that have high acquisition costs, are difficult to manage, and present reimbursement challenges.”
Part of the high costs of these drugs stems from physician markup which Bryant indicates can bring a 300 to 400 percent return on investment for some specialties through the buy-and-bill model. Reimbursement through a specialty pharmacy more closely resembles a Medicare methodology, lowering reimbursement amounts significantly, sometimes covering little more than acquisition costs.
For now, Bryant says, payers are operating on an optional model with few health plans requiring mandatory usage of specialty pharmacies, but cautions that health care providers should be aware that they will have to deal with them in the future, and prepared for both the benefits and challenges that they present.
Benefits of specialty pharmacies to physicians
The Silver Lining
1) Some of what you’re losing by adding a specialty pharmacy into the monetary equation, you’ll gain back in terms of outsourced business processes.
2) Though “practices must prepare for the changing trends in payers’ approaches to injectible therapy management,” Bryant says that providers should not assume they must accept a move to a mandated specialty pharmacy just because they receive a strongly worded letter from a payer. Because the specialty pharmacy largely removes drug purchasing as a revenue center, payers understand that physicians will want (and need) to make up costs elsewhere and will mostly be open to negotiating various fees.
Bryant recommends negotiating infusion, case rate, facilities, administrative, and professional fees. These are justified, says Bryant, because they will “support patients’ in-office infusions and allow your practice to remain dedicated to patient care and access.”