There are many factors to consider when developing a specialty pharmacy program. To help get started, score your facility on the factors below and then use the category descriptions to plan your specialty pharmacy model.
1) Does the health system have a self-insured health plan? (2 points)
2) Does the health system have a large staff of employed specialty physician practices
- >10 specialists (1 points)
- >25 Specialists (2 points)
- >50 Specialists (3 points)
3) Is there access to 340B pricing? (3 points)
4) Is the health accepting risk, such as participation in an ACO (1 point)
5) Does the health system have a large employee and beneficiary base
- >500 employees (1 point)
- >1,000 employees (2 points)
- >5,000 employees (3 points)
- >10,000 employees (4 points)
6) Are you large enough to gain access to payer contracts? (1 point)
7) Does the health system have an outpatient pharmacy (1 point)
Tally your results. Hospitals typically fall into one of these three categories:
≤3 Points: Independent Small to Moderate Size Hospital
Smaller organizations often do not have the resources to establish and support a wide-ranging specialty pharmacy program, but you will often find that a sigfificant and very attractive opportunity still exists. In this situation, you might want to look outside sources to partner and help you manage the opportunity, or concentrate on a select number of clinical areas (e.g. Oncology) from your outpatient pharmacy.
4-5 Points: Large Size HospitalsThe large size hospital category represents hospital with 300-500 beds and may have established outpatient pharmacy services. In this case, the pharmacy should fill prescriptions that are open access for Medicare Part D and where they can establish payer contracts. They should also implement reimbursement support and clinical support services for their patients. This type of hospital should also seek savings from the employee base through structuring the employee benefit plan to use the hospital’s specialty pharmacy for all specialty drugs that can be provided.
>6 or More Points: Significant Specialty Pharmacy Opportunity
The last category represents the type of hospital system that should have a specialty pharmacy with breadth and depth across all functions and specialty clinics. The hospital should look to implement at least some aspect of a specialty pharmacy operation over the next 6 months. It is an enormous opportunity! You should focus on hiring the expertise to implement, manage and service the pharmacy and start to build it from the ground up, however, in the interim, you may look to outsource some key functions.
340B health systems with more than 10 specialists in key clinical areas will find that their profit opportunity is typically large enough to support a specialty pharmacy. Most often, larger 340B eligible hospitals are able to successfully build the infrastructure to support a specialty pharmacy program, but it takes some time. In this case, the organization could sign agreements with one or more contract specialty pharmacies as an interim measure until it builds its own operation. Smaller 340B organizations might look to keep their clinical focus areas to the few that pose the biggest opportunities while outsourcing others, or they may look to outsource, partner and contract with organizations that can help with these services.
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