Shields Health streamlines prior authorizations

A Virtual Solution for Taming Prior Authorizations

By Karen Blum

Phoenix—A novel virtual networking and education initiative established by Shields Health Solutions for pharmacists, pharmacy technicians and other providers at its more than 20 health-system partners has succeeded in streamlining prior authorizations (PAs) and copay assistance for patients.

Shields Health Solutions established its specialty pharmacy Community of Practice (CoP) program in late 2020 to aid in the management of four disease states: diabetes, infectious diseases, autoimmune conditions (rheumatology) and neurology. The CoP program incorporates continuous learning opportunities and a platform for collaboration, said Kuwan Blake, CPhT, the company’s manager of communities of practice, who presented early results of the program at the 2022 ASHP Summer Meetings and Exhibition (poster 26M).

Each disease community has its own subject matter expert (a pharmacist) and three pharmacy technicians who help with training and patient support. The technicians are trained to handle all pharmacy needs for patients, including submission of PAs, investigation of financial assistance options and coordination of timely medication refills.

Each community hosts virtual monthly meetings and quarterly webinars led by the leadership team or guest speakers, covering topics aimed at improving patient outcomes, as well as manufacturer-led sessions about PA criteria, copay assistance programs and new drug approvals. All meetings are recorded and archived for later viewing by community members as needed, Mr. Blake said. Teams also conduct one-on-one meetings with health-system staff.

Topics for the meetings and webinars originate from the leadership team based on observations and recommendations from the communities and business analytics reports. Since launching, the CoP program has grown to 185 members in the infectious disease community, 205 in the autoimmune community, 112 in the diabetes community and 117 in the neurology community. The program attracted an average of 180 attendees across all meetings from January to March 2022. Initial review of inhouse data for a disease state supported by a CoP versus a disease state unsupported by a CoP showed an 18% average increase in PA approval rates. Specifically, PA approvals in 2021 were 79% for rheumatology and 74% for neurology versus 61% for oncology and 64% for transplantation. The latter two areas were not covered by CoP programs. The average medication copay was $8 for rheumatology and $5 for neurology, compared with $10 for oncology and transplant medications.

A subsequent review of the data comparing each specific CoP disease state from the second quarter of 2020, before the communities launched, with the second quarter of 2022 demonstrated a 27% average increase in PA approval rates, and maintained or reduced patients’ out-of-pocket expenses.

“For [professionals working with] a lot of our disease states, specifically diabetes, sometimes it’s a pharmacy desert,” Mr. Blake said. “They may feel isolated and not close to other pharmacy technicians or pharmacists.” In contrast, being part of the CoP community, which is virtual, connects those professions “to someone who’s just like you, and who supports the business just like you,” he said. “It increases employee satisfaction, because you feel like you have resources. But also, you’re learning, which is helping our patients.”

Shields Health Solutions is expanding the initiative, Mr. Blake noted, starting with the launch of an oncology community in May 2022 and the impending launch of a transplant community.

Mr. Blake reported no relevant financial disclosures other than his stated employment.

Adding a Pharmacist Enhances Dermatology Specialty Clinic

By Sherree Geyer

Phoenix—Adding a dermatology pharmacist to the care model improved continuity and access to specialty drugs, according to a presentation at the 2022 ASHP Summer Meetings and Exhibition.

The initiative extended a service model that succeeded previously in digestive health and rheumatology, according to lead author Youna Kang, PharmD, BCPS, a pharmacy resident at Yale New Haven Health in Woodbridge, Conn.

For the new initiative, Dr. Kang and her colleagues set a goal of phasing in five pharmacists and 2.5 technicians over a year, with three pharmacists aligned with specific dermatologists, regardless of practice sites. The study set several prescription target goals between Oct. 1 and Dec. 31, 2021, including 56 referrals (55 received), 77 prescriptions captured (44 predetermined), and 28 adjudicated or dispensed (37 predetermined).

“Our first pharmacist was implemented in the clinic six or seven months ago, in addition to the two implemented in March,” Dr. Kang told Pharmacy Practice News. “So, the data’s still young. We’re looking at how many patients are being referred to our pharmacist; how many prescriptions are sent to our health-system pharmacy; and how many of those we adjudicate and dispense. Sometimes we’re playing a little catchup to reach our target.”

Payor requirements have been a challenge, she noted. “A lot of patients are locked out because of insurance requirements and can’t fill with us. We’re hoping by the end of the fiscal year, we’re able to catch up to where we need to be.”

There also are clinical roadblocks to overcome in ambulatory outpatients, who typically present with psoriasis, eczema and alopecia, Dr. Kang noted. These diseases “are difficult to manage,” she said. “The population seemed like a good fit for what we could provide. They use a lot of medicines offlabel, and many are high-cost specialty drugs that can be difficult to access. We tweaked the [care] model, based on discussions with our dermatology clinician champion who provided great feedback to make it fit for that population.”

There were several barriers to achieving service outcomes. “The biggest limitation was the dermatology pharmacist wasn’t implemented until about November or early December, kind of end of the quarter of the fiscal year,” Dr. Kang said. “So, a lot of the data looks a little low for Q1, but it wasn’t a full quarter.”

As noted, insurance barriers also emerged, including delays in prior authorization (PA) approvals. Despite those delays, “we’ve exceeded the target for [PAs], but those dispensed prescriptions are the kind of limitations we’re running into. Some of the logistical things are not in our control because of time delays. So, there is still a little bit of a ramp-up we’re still doing.”

Future directions, Dr. Kang noted, include confirmation and assessment of clinical outcomes, continued optimization of the model, and expansion of services to additional dermatologists.

Assuming those results confirm the encouraging initial findings, Dr. Kang said she believes her team’s project can serve as a model for the implementation of an integrated dermatology pharmacist for other health systems.