Specialty Pharmacy and Value based care

Traditional vs specialty pharmacy

Specialty deals with complex conditions and complex meds while providing comprehensive services

Need constant monitoring and adjustments, need lots of patient training and specialized training and stuff

Clinical assessment process flow

initial assessment

follow up assessment

interventions

4 Challenges of patient care for specialty

Administrative barriers

Care complexities

High costs

Fragmentation across providers, health plans and pharm manufacturers

9 Classic TRC services

SDOH screening

24/7 nurse

Specialty clinical care management

Adherence, support tools, social worker stuff

Speical staff like dietitians asnd stuff

Fee fro Value

Provider payments based on value of care, reduce duplication of services, is value based stuff, lots of models

5 FFV payment models

Outcomes based contracting

Quality based network

Accountable carfe organizations

patient centered medical homes

Bundled paymetns/episodes of care

ACOS description

Medical neighbors, lots of diff things working together

Medical homes/PCMH description

Provide comphresnsive care, not always financial incentive to participate, quite expensive

6 value based metrics

ED visits

Inpatienta dmission

total cost of care PMPM

Generic dispensing rate

Total medical expenditure

HEDIS/star measures

Bundled payments/episodes of care description

Target price predetermined, providers shared in loses and savings between target price and actrual coosts

Invovle everyone for a fixed period

Seen with labor and delivery

Quality based networks

Incentive payments from health plan to retail pharmacy based on quarterly basis and performance

gaps include: med adherence, statin use in diabetes and CV CMRs, high risk meds in elderly

3 parts of value based care

Quality of care, provider performance, patient experience

4 CHallenges with value based care

Economic

Complicated metrics

data sharing

time consuming

How to solve challenges with VBC

Integrated delivery systems, join with others to form a network/CINS