Serving managed care, health-system and specialty decision makers Volume 10 • Number 4 • July/August 2021 • specialtypharmacycontinuum.com
UP FRONT
Rx delays, financial burdens cited in AMA survey
Connect with SPC online......3
Prior Authorization Ills: No Rest During COVID
OPERATIONS & MGMT Top 11 triggers for Medicare audits ............. 4 The per-patient cost of CAR T-cell Rx tops $2 million ....................... 7
As payors push patients out of hospitals …
It’s Prime Time For Ambulatory Infusion Centers
T
he time is ripe for ambulatory infusion centers (AICs) to gain a stronger foothold in U.S. health care, a panel of experts said during the MHA 2021 Business Summit, held virtually. “There’s a lot of tailwinds in this industry,” said Reece Norris, JD, a cofounder and the CEO of WeInfuse, an infusion software and consulting company. Payors and health plans are looking for sites of care (SOC) for infusion therapies that are more cost-effective than hospitals without compromising
Medicare loses billions when generic drug use falls short ................................ 14
Continued on page 9
POLICY Manufacturers and payors: finding a safe harbor for compliance .....................18 Some providers, payors push back on Alzheimer’s Rx ............ 20
REVIEW ARTICLE
The New Frontier Of Hemophilia Treatment See page 22.
Amid challenges … A
N
Health Systems Still Fighting for Specialty Access
ine of 10 physicians reported d that prior authorizations (PAs) s s) have had a negative effect on clinicall outcomes their t ffor th i patients, tii t and d nearly l one of three (30%) reported that PAs have led to a serious adverse event for a patient in their care, according to a survey from the American Medical Association (AMA). Almost four of five respondents (79%) said patients abandon treatment due to struggles with their health insurers over treatment authorization. In the early days of the COVID-19 pandemic, such hassles eased because many payors temporarily relaxed their PA requirements “to reduce administrative burdens and support rapid patient access to needed drugs, tests and treatments,” said AMA President Susan R. Bailey, MD, in a statement accompanying the release of the survey. By the end of 2020, however, as COVID-19 cases surged, “the AMA found that most physicians were facing strict authorization hurdles that delayed patients’ access to needed care.” Payors and pharmacy benefit managers (PBMs) counter that they have, in fact, sought to alleviate burdens imposed by PA requirements during COVID-19, with adjustments made throughout the pandemic. “Early in the COVID-19 pandemic, Prime Therapeutics removed all medication refill restrictions for our approximately
ealth systems continue to make significant inroads into the specialty pharmacy market, with more than two-thirds of multihospital systems launching programs in a recent fiveyear period. But despite those gains, the sector still faces major roadblocks, including a lack of access to limited distribution drugs (LDDs) and payor contracts, according to ASHP’s inaugural National Survey of Health-System Specialty Pharmacy Practice. Still, many health systems have succeeded in overcoming those challenges,
Continued on page 16
Continued on page 10
Special section:
ASHP SP Conference See pages 10 through 13.
H