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How Specialty Infusion Providers Help Payers Manage Risk Without Compromising Patient Outcomes

close up shot of a specialty infusion drip

How Specialty Infusion Providers Help Payers Manage Risk Without Compromising Patient Outcomes

close up shot of a specialty infusion drip

To manage risk successfully, payers must constantly balance patient care and cost. One way to advance value-based care that is proving successful for payers is partnering with a specialty infusion provider (SIP) that offers specialty pharmacy and infusion services as strategic, customizable programs that benefit payers, providers, and patients. 

The positive impact of specialty pharmacies on patient care for clinical and nonclinical outcomes has been demonstrated in several studies,and SIPs have proven they are significant partners in managing payer risk. SIPs have been called “safety nets” for payers because they streamline the medication delivery process and help patients navigate the complexities of care delivery and the insurance landscape. 

There are five key features/advantages that have helped SIPs grow into a major force in healthcare delivery and a crucial partner and resource for payers. 

  1. Comprehensive Medication Management

With specialized knowledge in complex therapies and medication administration, specialty pharmacies offer timely medication access through accurate dispensing, quick turnaround times, and care coordination. Helping patients navigate a complex system so they can receive and stay on their medications positively impacts both patient outcomes and payer costs.  

Specialty medication distribution and administration services include: 

  • Benefits investigation: SIPs are experts at understanding regional and national coverage plans. They explore each patient’s benefits, pay close attention to the details, and uncover payment assistance resources to manage costs.  
  • Prior authorization: Dealing with prior authorizations can be complex and time-consuming for payers and patients. SIPs can streamline this process by providing thorough documentation and clinical justification, ensuring patients receive timely access to necessary medications while adhering to payer requirements. 
  • Appeals processing: SIPs guide the appeals process, helping remove financial barriers that may deter patients from sticking with a treatment regimen. 
  • Clinical Assessments, Consultations & Follow-ups: SIPs provide continuous patient monitoring, coordination, communication and education, empowering patients to stay engaged with their treatment and achieve lasting results. 
  • Refill Support: SIPs have systems that coordinate with patients, providers, and payers to ensure medication is refilled on time.  
  1. Cost Management

SIPs can help payers manage the costs associated with high-price medication and specialty treatment by: 

  • Cost-effective medications and therapies:  SIPs focus on value-based care and use cost-effective medications and therapies when appropriate.  
  • Formulary management: SIPs payers drive biosimilar and other medication utilization by working directly with providers to initiate a medication switch and educating them to elevate their comfort level with the change. 
  • Ensuring patients get the right medication at the right time: Helping patients start and consistently stay on their treatment may result in lower downstream healthcare costs (e.g., fewer acute events, chronic health flare-ups, and hospital admissions).  
  • Clinical management and adherence programs: SIPs provide comprehensive clinical management programs that focus on patient adherence to prescribed therapies. For example, California Specialty Pharmacy (CSP) offers one-on-one education, nursing support, medication reminders, regular check-in calls, and 24/7 on-call customer and pharmacist support. CSP works alongside payers to track, report, and support adherence, ensuring patients achieve the best possible health outcomes. Site of care optimization: SIPs assist payers and providers in determining a patient’s optimal location for specialty medication and infusion therapies and treatments. One example is the shift of IV/infusion therapy delivery from hospitals to ambulatory infusion centers (AICs), which can be more comfortable and convenient and less costly for patients. This is why CSP provides infusion therapy at three AICs in California and three in Hawaii, operating as Hawaii Specialty Pharmacy. 
  • Regulatory compliance and quality assurance: SIPs are dedicated to continuously improving processes to safeguard patient health, enhance treatment efficacy, and maintain full alignment with industry and government standards. CSP builds trust with patients, healthcare providers, and industry partners alike by ensuring safety and quality requirements through rigorous protocols. 
  1. Quality and Outcomes Tracking and Reporting

SIPs like CSP collect data on patient outcomes, medication adherence, and healthcare utilization. They analyze this data to identify trends, predict patient behaviors, and provide actionable insights to payers.  

This information helps payers make informed decisions about coverage policies, formulary management, and resource allocation. By demonstrating positive outcomes and adherence to clinical guidelines, they can help payers meet quality benchmarks and improve overall healthcare quality. 

  1. Patient Support and Education

SIPs often offer personalized patient support and education programs. By empowering patients with information about their conditions and medications, they can improve self-management and reduce the likelihood of complications or emergency interventions. CSP provides a high level of tailored customer service that reflects well on the payer and helps reduce downstream costs for all stakeholders. 

  1. Collaboration and Communication

Effective communication and collaboration between SIPs, patients, payers, and healthcare providers is crucial for managing payer risk. SIPs can facilitate communication channels, coordinate care transitions, and ensure all stakeholders are aligned in providing optimal patient care. 

By aligning our services with the goals of payers, hospitals, health systems and pharmaceutical partners, CSP builds an integrated care approach that supports each patient’s journey, fosters open communication, and accelerates access to innovative therapies. 

SIPs Are Critical Partners in Managing Member Health 

SIPs help payers manage risk by improving clinical outcomes, controlling costs, improving patient adherence, and providing valuable, data-driven insights to support payer decision-making. Their specialized services and focus on high-cost, complex medications make them integral partners in the healthcare ecosystem. 

As one of California’s leading SIPs, CSP partners with payer organizations around the country, including specialty providers and medical groups, independent physician associations (IPAs), management service organizations (MSOs), and regional and national health plans. 

To learn more about CSP’s services and how we collaborate with payers, visit: https://csprx.com/servicess/  

References: 

  1. Zuckerman AD, Whelchel K, Kozlicki M, et al. Health-system specialty pharmacy role and outcomes: a review of current literature. Am J Health Syst Pharm. 2022;79(21):1906-1918. https://pubmed.ncbi.nlm.nih.gov/35916907/

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