As Disease Management companies discover convincing ways to make a business case for their services, specialty pharmacy is being held under a similar microscope to prove the value of what it offers. Or is it?

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Chip Phillips, chief operating officer for PharmaCare Specialty Pharmacy, also in Providence, agrees that disease management has an advantage when it comes to measuring outcomes: primarily, access to medical claims information and management of less complex, more common chronic diseases.

"However, many payers do not yet have detailed disease management strategies around their specialty pharmacy patients; they have tended to focus first on congestive heart failure, diabetes and asthma members as a result of the sizeable costs associated with those patient populations," Blaylock says.

"We have an active dialogue with our payers concerning what information is appropriate for us to collect and is valuable to them," he continues. "Payers' needs regarding clinical information and outcomes from specialty pharmacies are leading—in some respects—to a bifurcated market: those payers with extensive clinical data requirements who rely on their specialty pharmacies to help manage their members' care, and payers who are interested in their specialty pharmacy providers for principally distribution services."

HEALTH INSURERS EXPLAIN EXPECTATIONS

Pharmacy directors at several health plans have their own takes on what to expect from specialty pharmacy with some insurers accepting more responsibility than others.

"We already know outcomes from certain drugs or they never would have been placed on formulary," says Richard Bruzek, vice president of pharmacy services at HealthPartners headquartered in Bloomington, Minn. "Our primary interest is tracking compliance, persistence and appropriate use of medications, which we do through quarterly utilization data from CuraScripts [HealthPartners' exclusive vendor]." He admits that since CuraScripts does not have access to medical data, the job of tracking outcomes becomes the health plan's responsibility.

Bob Wanovich, director of clinical pharmacy services for Highmark in Pittsburgh, goes as far as to say that the health plan is not asking specialty pharmacy to be part of the solution. "We have the claims data and are doing most of the outcome analysis," he says. "Specialty pharmacy helps us coordinate care with physicians and patients, and to the extent that we can use it as a resource, we will take advantage of the opportunity. But as far as measuring outcomes, the plan is responsible."

Wanovich says that Highmark focuses on developing a value statement around expensive specialty drugs and tracks measures such as emergency room visits, hospitalizations and costs before and after therapies.

Jeff Casberg, director of pharmacy at ConnectiCare in Farmington, Conn., receives reports from his specialty pharmacy vendors, including compliance and utilization changes, transition of therapies, customer satisfaction, savings and the number of patient interventions, but that these data only predict outcomes.

For example, specialty pharmacy may track compliance, which should lead to better outcomes; show an increase in patient interventions potentially resulting in improved patient education; or measure transition rates for medications such as the four for multiple sclerosis, translating into less relapse. He notes, however, that no hard evidence exists to support these outcomes.

"Specialty pharmacy has to get the basics—dispensing drugs appropriately and providing good service—down pat before they can share clinical outcomes," Casberg says. "Specialty pharmacy is still in its infancy."