Proceedings of the ASHP Specialty Pharmacy State of Practice in Hospitals and Health Systems—Future Directions Summit

February 1–4, 2021

Address correspondence to David Chen ([email protected]).

On February 2–5, 2021, over 150 pharmacists and other key stakeholders convened for the ASHP Specialty Pharmacy State of Practice in Hospitals and Health Systems — Future Directions summit to discuss key issues impacting specialty pharmacy practice in health systems and future directions. Summit participants ( Appendix A) also agreed upon recommendations to guide best practices and support sustainability and future growth of health-system specialty pharmacies (HSSPs). In order to stimulate thought-provoking and futuristic thinking by conference participants, the summit included 2 plenary sessions and 2 panel discussions led by thought leaders in the industry (Box 1). The plenary sessions were kicked off with an overview of the specialty pharmacy market and projected market trends. This was followed by a “state of the union” presentation guided by the first public release of survey results from the first ASHP National Survey of Health-System Specialty Pharmacy Practice. In addition to the survey results, insights and interpretation of results were shared to highlight possible best practices as well as gaps, which can also be viewed as potential areas of opportunity. The panel discussions held on the second day of the summit provided stakeholder perspectives, with a particular emphasis on value-based care delivery. The first panel focused on quality and outcomes evidence gained through research, which is needed to support a value-driven future. Panelists included a health-system specialty pharmacist and representatives from industry and academia. The second panel provided industry expert and payer stakeholder perspectives on the shift in the specialty drug industry to value-based payment and how HSSPs can support, and even lead, the creation of a high-performing, value-based model of care. These proceedings summarize session highlights, speaker insights, and key takeaways from the panelist discussions that provided context to the broader summit objectives, including development of recommendations for advancement of hospital and health-system pharmacy practice (Table 1).

Market overview and trends

In the first plenary session, futurist Bill Roth, founding partner of the Blue Fin Group, set the tone for the summit with an overview of the specialty pharmacy market and trends. Roth noted that historically, the specialty pharmacy market strategic focus was on creating the business model, optimizing purchasing, managing the drug spend, understanding network design, and generating revenue. For the summit, the focus was on outcomes. According to proprietary research conducted by the Blue Fin Group in 2019 and 2020, HSSPs are poised to drive desired outcomes; on average they have less than 5% prescription abandonment, 0 days time to fill, and 5% adherence loss, outperforming all others in the industry. HSSPs need to understand how to position this level of performance within a delivery system currently controlled by payers and, to some extent, manufacturers. By and large, the payers have set the rules of the game, but Roth believes HSSPs are learning to play the game. Industry consolidation and a subsequent increase in market share have strengthened the payer position; however, with the shift toward outcomes-based performance, HSSPs have the opportunity to reset the rules and “to be the board, not just one of the pieces.” Roth pointed to 3 strategic windows of opportunity driven in part by the Affordable Care Act: holding providers and systems accountable for outcomes, reimbursement reform with a shift from fee-for-service to value-based payments (and penalties), and requirements for more transparency. Strategically, then, HSSPs need to consider their services more broadly, across all settings, as a “holistic enterprise pharmacy,” with a focus on delivering outcomes.

Health-system specialty pharmacies need to consider their services more broadly, across all settings, as a “holistic enterprise pharmacy,” with a focus on delivering outcomes.

—Bill Roth, Blue Fin Group

From the payer point of view, alignment with the health system and providers is key in controlling costs, and payers are particularly focused on controlling the spend on cell and gene therapies and orphan and rare therapies in addition to the specialty medical and pharmacy benefit. Their shift to outcomes-based reimbursement is one opportunity for health systems to shift and, ultimately, define an outcomes-based model that aligns incentives. Also, with HSSPs, the level of integration (regionally) with health plans is strong, as is their performance on traditional patient journey optimization (eg, improving the abandonment rate, average time to fill, and adherence rates).^1,2

Roth noted that while HSSPs are positioned to design and lead in an outcomes-based model, one challenge is that there is currently no standardization of metrics and currently reported metrics focus primarily on patient journey optimization, not outcomes. These service metrics are important to commercial business performance, but metrics must be developed to support outcomes reporting and value-based contracting. Looking at the bigger picture, a plan sponsor (such as a self-insured employer), is focused on retail prescriptions and the specialty drug spend, but as the ultrarare conditions spend (ie, expenditures for cell/gene therapies, orphan drugs, and drugs targeted to rare diseases) grows to account for more than two-thirds of the market, this is where the focus will shift, as well as the opportunity for impact. One advantage that can be leveraged by HSSPs is that they are the only channel that touches, or has the potential to touch, all of these areas.

For the most part, the HSSP business model has historically been more reactive than proactive, and tactical versus strategic. For example, many HSSPs are limited to dispensing employee prescriptions, with a focus on drug and payer access, and responding to manufacturer and payer requirements. Strategically, HSSP leaders need to consider external factors influencing their current business models and where they can align with stakeholders. For example, many HSSPs were developed to drive revenue associated with the federal 340B Drug Pricing Program, revenue that is likely to shrink over time. On the other hand, HSSPs have the opportunity to leverage their electronic health record (EHR) and physically embedded staff, which are the elements to produce a highly efficient and effective clinical care model that can drive outcomes and that will influence decisions by payers and manufacturers. To tell their story, HSSPs should look at outcomes as well as processes around high-priority therapies, those with the highest dollar impact, and more complex therapies. Available data (eg, data on care coordination, active therapeutic intervention, and comorbidities) can be used to show health plans what is being achieved, such as whether primary treatment endpoints are being met. All payers look at accreditation as an indicator of quality, so it may be a useful strategy to partner with specialty pharmacy accreditation bodies to align measures with the HSSP model for care delivery.

When developing business strategies, it is also important to recognize that payers have been moving toward vertical integration through inclusive ownership and managing of channels that control providers, pharmacies, and home infusion. The payer wants control and the revenues associated with a physical product dispense, which typically involves standalone specialty pharmacies that are not aligned with the complete patient journey. At best, a standalone specialty pharmacy can support only a prescription journey and not a patient journey. On the other hand, health systems view and manage the patient holistically and are effective at optimizing the patient journey. If manufacturers seek to enter meaningful value-based care agreements, they must consider the value that can be delivered by a more integrated HSSP model. While HSSPs stand to deliver against longitudinal therapy models better than any payers, they require the standards, benchmarks, and communication necessary to scale the required infrastructure.

Roth noted that one approach would be a hub-and-spoke information dissemination model whereby there is central thought leadership—perhaps by a council of strategic pharmacy corporate leaders—that creates standardized methodology and outcomes measurements, mechanisms for communication, and therapeutic area experts. Roth has worked with manufacturers directly in specialty and orphan/rare disease states that have seen as low as an 8% abandonment rate and an 8% adherence deficiency. This model creates a unified front, which elevates clinical practice and the patient experience, while taking a financial stewardship approach with the development of well-defined and measurable therapeutic outcomes. Through this model, health systems can deliver on the promise of proving their differentiation within the marketplace.

Roth had 5 key recommendations for moving forward with a unified approach: (1) standardize outcome and value metrics, considering alignment with stakeholders (plan sponsor and patients); (2) implement sharing of standardized peer-to-peer data; (3) create plans to mitigate reimbursement reform possibility (eg, 340B program changes); (4) actively engage with the health system’s payer team; and (5) promote performance to payers and manufacturers. One payer strategy that provides an example of this to consider is partnering with a large, self-insured employer. While national employers present more challenges, other large employers, such as a predominant plan in a region or state, have control over the design of their plans and network.

To summarize, there is considerable opportunity for HSSPs to offer a highly effective model for managing spend and ensuring optimal utilization of high-cost therapies, including the growing cell/gene and rare/orphan drug therapies. HSSPs are uniquely positioned in a vertically integrated market because they possess the full array of tools required to coordinate care and achieve therapeutic goals. If a central council of thought leaders drives industry standardization of processes and outcome measures that align with payer and manufacturer goals, HSSPs will be assured a place as preferred providers.

ASHP National Survey of Health-System Specialty Pharmacy Practice results

In the second plenary session of the summit, JoAnn Stubbings, BSPharm, MHCA, Clinical Associate Professor Emerita, Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, presented the preliminary results of the ASHP National Survey of Health-System Pharmacy Practice. The survey results provided timely context to the summit participants’ understanding of the issues facing HSSPs across the spectrum, as they describe the HSSP practice model and identify best practices and gaps that can inform the proposed summit recommendations. The results are interpretive and were open to debate and discussion among summit participants. A more detailed review of the survey results is now available.³ A review of the preliminary survey findings provided the audience with a sense of how the HSSP practice model is robust and unique, the extent to which HSSP services are integrated into health-system clinics, and methods to identify opportunities for improvement.

The survey was conducted in late 2020 and was completed by representatives of over 100 organizations. The survey questions addressed 8 domains: Health-System and Specialty Pharmacy Demographics; Workforce Staffing Levels, Training, and Credentials; Operations; Payer Access, Business Relationships, and Financial Management; Patient Care Services, Clinical Care, and Documentation; Quality, Outcomes, and Value; Staff Activities and Functions; and the Future of Specialty Pharmacy. The following sections highlight key survey findings as presented by Stubbings.

Demographics

Demographics indicate that HSSPs are well established and integrated into health systems, with the majority affiliated with a 340B-covered entity; many also dispense nonspecialty medications, and most are accredited. Most specialty pharmacies dispensed fewer than 30,000 specialty prescriptions per year and had gross revenue of less than $100 million in 2019—relatively small operations by industry standards. The top 5 therapeutic categories dispensed were consistent with industry trends and included agents targeting inflammatory conditions and hematology/oncology, hepatology, neurology, and infectious diseases. The HSSP business model is largely focused on the pharmacy benefit (versus medical benefit) claims, and less than 10% of HSSPs manage home infusion.

Workforce

Workforce domain responses indicate that most specialty pharmacies report through the pharmacy department, either to a chief pharmacy officer or to the ambulatory care pharmacy leadership. Specialty pharmacists and technicians are integrated into and dedicated to specific clinics, and pharmacists are involved in treatment decisions prior to the prescription being written. There are more hybrid, or mixed, practice models versus a generalist model (ie, all pharmacists are assigned to all clinics or disease states) or a specialist model (ie, pharmacists are assigned to a specific clinic or disease states). Stubbings considered the high level of integration a best practice. There do not seem to be consistent training or certification requirements for specialty pharmacists, which begs the question of whether training is keeping up with demands of the HSSP practice model. The advanced pharmacy practice experience (APPE) rotation for student pharmacists is the most common specialty pharmacy training offered by health systems, followed by an elective specialty pharmacy rotation in a postgraduate year 1 or postgraduate year 2 residency program. The majority of HSSPs perform patient care services related to documentation, monitoring, interventions, and patient assessments, most of which are required for accreditation. Less than half but still a notable percentage (about 30%) of specialty pharmacists are prescribing medications and ordering vaccines and laboratory tests. This indicates that there is an opportunity to expand services beyond those required for accreditation.

Operations

HSSPs are integrated operationally and clinically with their health system and have a local or regional reach that is, for the most part, payer agnostic. Although some payer contracts require licensure in all 50 states, most HSSPs have 1 to 5 licenses.

Payer access and business relationships

Over 80% of HSSPs have their own self-insured employee health plan, and HSSPs are most likely to be a preferred or sole provider of specialty medications. While this has resulted in a substantial fill rate (>50%) for employee prescriptions, there is room for improvement. This also points to the power of vertical integration within health systems and, consistent with Roth’s recommendations around payer alignment, suggests that other self-insured employers would also be interested in contracting with an HSSP to take advantage of that same integration for their employees.

HSSPs are less successful with network access for their own patients. Most HSSPs fill 50% or less of specialty prescriptions originating from their health system’s providers.

Although HSSPs have had moderate success in gaining access to limited-distribution contracts, there is significant opportunity to improve. The most frequent barriers cited include manufacturer refusal to engage and being blocked out by payers. To enhance access, HSSPs are actively helping patients to access their medications by managing a variety of patient assistance programs that save patients millions of dollars each year.

Patient care services, clinical care, and documentation

The top 5 clinical services provided by HSSPs are prior authorization support, adverse effect identification and management, providing medication refill reminders, offering copayment assistance programs, and adherence support. Although these are also the most common services required by accreditation organizations, some HSSPs are offering more advanced activities, although to a lesser extent. These types of advanced activities, such as comprehensive medication management services, conducting patient care visits with clinic-embedded pharmacists, and making dosage adjustments by protocol, are an opportunity for growth. Of the survey respondents, 40% stated that their specialty pharmacists operate under collaborative practice agreements, and 35% of respondents stated their organization has a credentialing and privileging process for pharmacists. HSSPs are positioned with highly skilled practitioners, likely with more training than pharmacists in other sectors of the market, particularly HSSPs with an integrated or hybrid clinical model. Stubbings proposed that specialty pharmacy residency training would further advance the level of practice. This will become even more important as value-based contracting and limited distribution networks will demand high-value outcomes. Most HSSPs do not seem to be billing for nondispensing services, but some are billing for services such as telehealth, medication therapy management services, and patient education, which indicates there is an opportunity to bill for more services. Likely distinguishing HSSPs from other specialty providers is that almost all have 2-way access to a patient’s EHR, considered now to be a best practice. Finally, most health systems allow “clear bagging” of specialty injectable medications and “white bagging” to a lesser extent, but “brown bagging” is mostly not allowed. Stubbings noted that clear bagging is an opportunity for HSSPs to build their business and expand into the medical benefit, since the HSSP will provide specialty injectable medications directly to its infusion clinics.

Quality, outcomes, and value

Having a quality improvement program is a best practice for HSSPs, and required elements are outlined in accreditation standards. However, there are differences in what is being measured. To show value, HSSPs most commonly measure patient and provider satisfaction, revenue, improved clinical outcomes, and safety. Process measures (eg, prescription volume, dispensing accuracy), financial measures (eg, financial assistance, cost savings), and clinical measures (eg, proportion of days covered, disease outcomes) were also commonly reported in the ASHP survey. Stubbings believes there is opportunity to measure and report additional clinical metrics and patient-reported outcomes to demonstrate value. HSSPs are also heavily involved in the prior authorization process. Almost half of HSSPs report an approval rate over 90%, a health-system best practice. The average HSSP has 13 pharmacist and 15 technician full-time equivalents (FTEs). On average, each pharmacist or technician FTE processes only up to 100 prescriptions per day and manages up to 50 patients per day, which speaks to the intensity of the service.

The future of specialty pharmacy

The survey respondents indicated that top challenges HSSPs expect to face in the next year are in the areas of access to payer networks, 340B Drug Pricing Program changes, shrinking reimbursement from payers, and access to limited-distribution drugs. Access to payer networks is critical to HSSP survival and is top of mind for everyone. Stubbings concurred and noted during the summit the need for a “big idea” to address this problem. The top opportunities for HSSP growth are driven by a natural growth that arises from introduction of new drugs that address new indications and that address new populations. This is consistent with survey responses that top opportunities for HSSP growth within the next 1 to 5 years are new populations, new therapeutic categories, and patient engagement through telehealth. There may also be an additional opportunity to redefine the specialty patient as high risk patient and include other drugs as well, because the integrated model is well suited to support a broader group of patients requiring complex medication therapies.

Patient satisfaction and level of service are consistently among the top 3 points of pride that HSSPs have been exceptionally successful in achieving. Payer contracting is the top priority in the HSSP strategic plan for next year, followed by reporting clinical outcomes, reporting capabilities, and expanded access to limited distribution drugs.

Based on her review of the survey results, Stubbings proposed that summit participants consider the following strategies as priorities to address gaps and opportunities:

• Gain access to payer and limited distribution networks.

• Expand the specialty practice model to include the medical benefit.

• Implement advanced clinical services such as ordering prescriptions and telehealth, and bill for those services.

• Require pharmacist credentialing and privileging to support advanced practice.

• Develop specialty pharmacy residency training to support advanced practice.

• Incorporate specialty pharmacy training into undergraduate experiential education.

• Create a pharmacy technician career ladder (training, pathway, salary, education) to support advanced roles.

• Expand measurement and reporting of performance metrics.

• Demonstrate and disseminate outcomes and value.

In conclusion, the survey results provide evidence that the HSSP practice model is robust and unique and provided context and insights for summit participants as they considered recommendations for HSSP practice.

Value-Driven Future—Quality and Outcomes Evidence Through Research (Panel 1)

Session Moderator Lynnae Mahaney, BSPharm, MBA, FASHP, Senior Director, Pharmacy Accreditation, ASHP, led an in-depth discussion on implications of a values-driven future for specialty pharmacy and considerations for building quality and outcomes evidence through research. Mahaney described an urgent need for outcomes research and results sharing by HSSPs so that the excellence of care they provide can be validated in a market that requires quality, outcomes, and satisfaction to compete.

When the Institute of Medicine (since renamed the Academy of Medicine) published the reports To Err Is Human: Building A Safer Health System in 1999 and Crossing the Quality Chasm: A New Health System for the 21st Century in 2001, one of the standout findings was that only 55% of patients received recommended care.⁴ Since those reports, the US healthcare system has begun to shift focus from “payment for quantity” to “payment for quality,” driven in part by the Affordable Care Act, which directed the US Department of Health and Human Services to establish a National Quality Strategy to improve the delivery of healthcare services, patient health outcomes, and population health.⁵ The U.S. Healthcare Quality Strategy, known as the “Triple Aim,” strives to improve care and provide better outcomes at a lower cost. This has recently evolved into the “Quadruple Aim,” with an added goal of a better clinician experience. There are 6 priorities within the National Quality Strategy, all of which can be affected by HSSPs: (1) safer care; (2) patient-centered care; (3) effective communication and coordination of care; (4) effective prevention and treatment practices for the leading causes of mortality; (5) healthy living, including efforts to address social determinants of health; and (6) quality care that is affordable. Accountability for quality begins with clearly defined goals that can be measured and monitored and are recognized and utilized by all healthcare stakeholders. Furthermore, the consequences of achieving or falling short of these goals should be clear among all parties. Accountability measures for specialty pharmacies have historically been process oriented (eg, turnaround time and call center metrics), and these have been integrated into pharmacy network inclusion criteria and value-based payment contracts. In real-world practice, outcomes-based quality measurement for specialty diseases and medications may sound simple yet can be very difficult to implement, and few of the measures are standardized across the industry.

The Pharmacy Quality Alliance has developed standardized measures for certain specialty conditions, including medication adherence in multiple sclerosis, antiretrovirals, rheumatoid arthritis, and hepatitis C therapy completion.⁶ Though important, these measures are limited and foundational in assessing quality outcomes related to specialty medications. A value-driven future for specialty pharmacy is dependent on quality and outcome measures that are evidence-based, aligned across specialty pharmacy stakeholders, and widely communicated. To gain this alignment, it is essential to partner with internal and external collaborators to define critical elements necessary for meaningful and translatable outcomes-based research (ie, research to associate core process measures with desired outcomes). There is currently a paucity of validated measures that will translate to outcomes, including achievement of the expected therapeutic response or control of disease. Reduced utilization (eg, hospitalizations and emergency department visits), patient satisfaction, and quality-of-life measures are also commonly used value-based measures and are often used as surrogates for assessing disease control. Mahaney noted that outcomes reporting may also require use of a surrogate measure that can be correlated with a financial benefit (eg, work days lost).

Recently, there has been much interest in total cost of care (TCOC) measures as well. Measuring TCOC has been a challenge for health systems because of limited data available within the system itself and difficulty determining direct cost attribution. It would be necessary to partner with payers to assist with the data, as described in a report on a study by Soni et al⁷ wherein the researchers compared per-member per-month costs for patients within an accountable care organization who were served by an integrated specialty pharmacy versus a nonintegrated specialty pharmacy.

Research framework for health-system specialty pharmacy

The panelists for this session, representing unique points of view, included an HSSP pharmacist and external stakeholders from academia and industry and were asked to share their insights and suggested approaches for developing a research agenda for quality, outcomes, and value in specialty pharmacy practice.

The first panelist, Autumn Zuckerman, Program Director of Health Outcomes and Research with Vanderbilt Specialty Pharmacy, addressed the importance of outcomes-based research to demonstrate HSSP value in an evolving marketplace that demands the highest level of care for patients. A framework for specialty pharmacy outcomes research should reflect 3 goals: first and foremost, to gain knowledge to improve patient care (eg, what steps an organization is currently taking and can take to optimize specialty treatments, contain costs, and improve patient access, adherence, and outcomes); secondly, to create or support the value proposition for an intervention; and lastly, to contribute to a scientific body of knowledge (Table 2).

Zuckerman noted that it is critical for HSSPs to collect, aggregate, analyze, and report on the services that are provided to patients. HSSPs should evaluate the outcomes of these patient care services and disseminate findings. Three critical elements necessary for conducting effective outcomes research and results sharing are (1) identifying and standardizing outcome metrics that are recognized industry-wide; (2) implementing disease state monitoring capabilities that incorporate outcomes metrics and allow for real-time assessment of therapy response; and (3) identifying and utilizing resources to perform and communicate results of outcomes research. Each of these elements poses opportunities and challenges (Table 3).

Standardized outcome metrics would enable aggregation of data across HSSPs. Standardizing metrics is challenging for several reasons, as many specialty disease states have either several or no quantifiable outcomes that can be measured to assess patient response to therapy and, once metrics are developed, it may or may not be feasible for HSSPs to collect data to measure them. Finally, it can be a challenge for HSSPs to know what metrics are most important to demonstrate value to stakeholders.

In order to operationalize the use of the metrics, documentation of patient care activities and patient outcomes must be structured in a way that is readily extractable and, ideally, provides real-time outcomes monitoring capability to providers (eg, through dashboards). These data can be used to design care interventions and identify patients at risk for poor (or better) outcomes. Reporting patient outcomes provides invaluable information to payers and manufacturers and will support value-based contracting. Lastly, building and communicating the specialty pharmacy value story needs to be integrated into business expectations. HSSPs should identify a dedicated resource to determine a research strategy, including priorities; oversee projects; and communicate research results. Allocating resources to research activities can sometimes be justified by showing increased access to contracts and therefore translate to higher prescription capture rates and patient retention. Additional challenges and opportunities are also shown in Table 3.

To conclude her presentation, Zuckerman shared tactics to improve measuring of quality, outcome, and satisfaction metrics to support the unique value of HSSPs. These tactics build on the elements noted above that are critical to the research agenda. First, researchers should develop, validate, and standardize measures unique to HSSP practice. Second, HSSPs should determine the resources needed to perform metrics monitoring. Third, the plan and outcomes must be recognized as valuable by the HSSP leadership. Finally, HSSPs must collaborate with stakeholders to understand “value” from their perspective and then communicate the value demonstrated. Though this is not a comprehensive list of everything HSSPs and the field in general will need, it provides high-level guidance on creating a path forward.

Research collaboration: perspective from academia

Panelist Betsy Sleath, Regional Associate Dean of Eastern North Carolina and the George H. Cocolas Distinguished Professor in the Division of Pharmaceutical Outcomes and Policy at the University of North Carolina (UNC) Eshelman School of Pharmacy, provided the academic perspective on developing a research agenda to support value-based models and shared her recommendations for study design, measurement and data elements, analysis of data, and dissemination of findings. Sleath believes that the specialty pharmacy research agenda needs to be outcomes focused, designed to demonstrate the effectiveness of pharmacist interventions, and strengthened through partnerships. For example, UNC has a “Partnership in Patient Care” between the UNC Health system and the school of pharmacy, and one component is research. Some examples of ongoing research resulting from this partnership include development of a predictive model to guide pharmacist prioritization in the care of medically complex patient populations and a study of adherence to oral cancer therapies. Ideal partners (organizations or providers) are known for their expertise in the area to be studied and have a sufficient number of patients to meet the study’s inclusion criteria. For some patient populations, such as those being treated for a rare disease, it may be necessary to partner with other health systems (eg, through reliance agreements).

Identifying a specific research question and establishing the research team are the first steps in designing and conducting research. A multidisciplinary team, including learners, can help to facilitate the institutional review board approval process, refine the question(s), and identify the capability of the systems in place to gather the necessary data. Some areas of current HSSP research interest include patient-centered outcomes, health literacy and disparities, the impact of telehealth (eg, phone versus Internet interactions), risk-benefit communication about medications and the impact on outcomes, and improving training of the pharmacy workforce.

Once the research question is determined, outcome measures should be selected. Sleath emphasized that validated scales should be considered first, but there may be a cost associated with using them. If there is no validated measure, then one can be developed or a surrogate measure used. It is imperative that data management analysts be engaged early in the research to confirm their support and to guide decisions, such as deciding how many patients are required to achieve study results of the desired statistical power. Consider partnerships that can bring needed support; for example, industry can sometimes provide research expertise, such as analytics support. Finally, it is important to disseminate research findings through presentations and publications. This can occur internally (within the health system) or externally through dissemination of results to other stakeholders (eg, other health systems, professional organizations, health plans, government agencies, and patient advocacy groups).

Research collaboration: perspective from industry

The final panelist, Cameron James, PharmD, CGP, MHCI, Medical Affairs Executive Director for Genentech, Inc. (a member of the Roche Group), provided insights from industry on collaboration between industry and health systems. When looking for opportunities to collaborate, it is important to understand what potential partners value. For example, James noted that a key research priority of value to industry is gaining an understanding and evidence of how well drugs work in real-world circumstances (this might, eg, inform what changes might be made in clinical trials to better determine clinical efficacy). Understanding real-world evidence can also help to develop expectations for value-based agreements. Another priority is understanding whole-patient care and how complementary care (as is often provided by HSSPs) provides an opportunity to learn about symptom and adverse effect management that goes beyond dispensing and administering a drug. For example, what interventions impact the additions and subtractions to the value story (cost-impact or cost-benefit models)? By working together, a research team can tailor the research to uncover additional pieces of the value puzzle.

Value to industry partners can include differentiation of a therapy (through, eg, patient follow-up to determine which patients do better, cases where the drug works, and when “one size doesn’t fit all”). Also, industry partners may be interested in specific populations that are different, not often discussed in the literature, or hard to reach, or they may be interested in testing a population that reflects the population in which a therapy is used in real-world practice. Organizational characteristics that lend themselves to successful and meaningful research partnerships with industry include a clear mission and goals for the research, having a champion within the organization who can push the research agenda, and demonstrating a history of conducting research. It is also an advantage to have expertise (in a therapeutic or operational area) unique to the research question or population. Finally, there needs to be good capability (or a plan) to capture the data. Collaborations with industry start with aligning incentives and goals. Industry opportunities and current research priorities are often posted on a drug company’s website. Look for requests for proposals from industry and reach out to medical affairs liaisons, who can provide a wealth of information. Also, consider that drugs have life cycles and that information on new drug pipelines and patent expirations is readily available. Finally, HSSPs seeking to form partnerships should look beyond the financial element of an industry partnership and, as Sleath noted, also recognize that industry partners can provide research expertise and support.

James stressed that meaningful collaboration is critical to an outcomes-based research agenda and begins with self-evaluation: what the specialty pharmacy currently does and what is wanted from collaboration—evidence-based therapy guidance, money, resource support, publication, partnership, or all of the above. Consider the research capabilities, strengths, and weaknesses of the team and the direction of the health system as a whole, such as a history of publications in a certain area, being considered a center of excellence, or a team member’s being considered a national expert as part of the medical team. The goal is to foster long-term relationships and create a win-win for everyone.

Collaboration with industry and academic partners will enhance the ability of an HSSP to conduct meaningful and translatable research demonstrating its impact on patient outcomes. There is an opportunity to align stakeholder goals to develop meaningful metrics that reflect high performance and value. Effective partnerships will support outcomes research and dissemination of results that are necessary for an HSSP’s continued vitality and to differentiate its services in the market.

Stakeholder Perspectives to Support Value-Based Care with Specialty Pharmacy Practice (Panel 2)

Udobi Campbell, PharmD, MBA, Regional Director of Pharmacy, UNC Health, served as moderator for the panel discussion. Campbell introduced panelists Gregory Dill, PharmD, Deputy Director for Innovation & Financial Management, Centers for Medicare & Medicaid Services (CMS), and Cedric Terrell, PharmD, MHA, Chief Pharmacy Officer and Vice President Health & Medical Management, Blue Cross Blue Shield of Massachusetts (BCBSMA), to provide payer perspectives on how outcomes can be strategically connected to health system–based specialty pharmacies to demonstrate value. These leaders provided their insights into industry trends, including the industry’s high-priority economic drivers, and how to align with payers.

Government policy drives shift towards value-based care

Dill provided an overview of the “state of the union” of US healthcare, particularly a review of Medicare key cost drivers and what is being done to manage those costs.a In fiscal year (FY) 2019 CMS had spending that exceeded $1 trillion, or approximately 15% of total federal outlays; in 2020, this figure increased by over 16%. CMS spending now exceeds that of the Social Security program.^8,9 The primary drivers of this shift are (1) healthcare inflation is growing faster than general inflation and (2) the increase in Medicare enrollment is at its fastest rate in history; by 2030, it is projected, there will be about 80 million Americans enrolled. Spending for drugs has also increased dramatically, from $17.6 billion in drugs (Part B, including specialty drugs) in 2011 to $28 billion in 2016. All of these factors merge to create a situation where expenditures are predicted to exceed income by 2026 for the Medicare Part A Trust Fund.¹⁰

While these trends are concerning, they also present an opportunity for HSSPs. When the risk of Medicare trust fund insolvency loomed in the past, Congress acted and, while it would be a politically questionable move, it is likely Congress will once again open the health policy window to address Medicare trust fund solvency. That window of opportunity is within the next few years, and health-system providers and advocacy strategists need to keep this “top-of-mind” to provide insights into solutions that support beneficiaries and the healthcare market. Another factor that will drive policy change is the high out-of-pocket expenses that Medicare beneficiaries are experiencing. In 2016, the average annual out-of-pocket spending was $5,460 per beneficiary, which exceeded 20% of the total average income for over a quarter of beneficiaries.¹¹

When looking at how to address these cost increases, prescription drugs, including specialty drugs, are near the top of the list of expenditures. With drugs, issues involve both cost and access. Policy options are complex and wide-ranging. In order to address the cost problem, CMS is doing several things now within the current policy structure: (1) working to expand value-based payments and pay-for-performance models; (2) putting providers at risk; (3) implementing formulary structures (specialty tiers), which previously had been more often used by commercial payer plans; (4) working with manufacturers to close the “donut hole”; (5) considering how to apply competitive acquisition pricing to leverage market forces; and (6) considering the application of “most favored nation” law to require that drug pricing in the United States be equal to what other countries pay.

Dill also noted that CMS has promulgated requirements for drug spending and hospital price transparency as another strategy to allow patients to make more informed decisions. CMS has created Medicare Part D and B dashboards that are publicly available.¹² The Part D Senior Savings Model for Part D drugs is another initiative to assist beneficiaries. The model’s goal is to make a stable, predictable copayment structure for beneficiaries across all benefit phases (deductible, initial coverage, coverage gap, and catastrophic). For example, the voluntary model has allowed Part D plans to provide broad access to multiple types of insulin, with a copay maximum of $35 for a 30-day supply in all phases of the Part D benefit.¹³ The Affordable Care Act has also allowed for experimentation with a number of other at-risk and value-based payment models. Physician and health plan quality measures have also been made transparent.

It is important that pharmacists understand what the quality measures are, making sure that pharmacists and all of the providers and entities that support the healthcare system can move the needle in the direction of achieving those quality measures. Medicare will also be launching more models that put providers and similarly situated entities at risk, such as the Medicare Shared Savings Program. It is important that all of the entities understand what defines value-based program success, then collaborate to get there. If an organization cannot drive quality, payment will be at risk.

To summarize, while Medicare solvency and cost challenges create a sense of urgency, they also present an opportunity for providers of all types to act now to develop strategies that support new models, particularly the shift from claims-based payment (ie, fee-for-service payment) to value-based payment (ie, paying for the best quality at a lower cost). All strategies must take into account outcomes and the beneficiary experience, particularly affordability and access to drug therapy.

Value-based payment: commercial payer perspective

BCBSMA’s Terrell provided a perspective of the evolution of value-based care from the view of a commercial payer responsible for a portfolio of approximately 2.5 million members. In 2019, healthcare expenditures accounted for almost 18% of the US gross domestic product, and 10% of that spending was associated with prescription drugs.¹⁴ Specialty drugs are driving steady increases in drug costs, and top categories include drugs used to treat multiple sclerosis, oncology disorders, and inflammatory conditions. The market is also seeing a shift to newer gene therapies that require expertise to deliver. However, gene therapies are more targeted and represent a one-time cost. However, the Food and Drug Administration could grant approval to 50 to 100 gene and cell therapies by 2025, with an associated projected cost of $13 billion in 2026.¹⁴

BCBSMA has approximately 1.4 million commercial pharmacy members and administers pharmacy benefits to both fully insured and self-insured accounts. Specialty drugs have a disproportionate impact on spending. In 2019, more than half of the Blue Cross total drug spend was for specialty drugs, but only 1.8% of the members received a specialty drug. Terrell noted that when considering strategies for managing specialty drug costs, it is important to understand the supply chain. For every $100 spent on prescription drugs, $41 goes to intermediaries in the supply chain, according to a 2017 report.¹⁵ Another study looked at costs in the pharmacy supply chain. The researchers noted that there is a multitude of players, which complicates addressing cost issues; and that when different models are tested, there is a need to consider how models benefit consumers, with the goal that they receive appropriate drug therapy.

Since 2009 the clinical management program at BCBSMA has aligned with value-based contracting since 2009, with a more global budget view versus fee-for-services. The Alternative Quality Contract (AQC) program initially emphasized prevention and gave flexibility to providers and health systems to implement innovative programs (eg, navigator-based and behavioral health programs). The impact of this program over time has shown that costs continue to come down. Overall savings associated with the value-based AQC program indicate phenomenal results with use of the improved patient care model and a slowing of healthcare spending by 12% (compared to spending growth in the New England region and the entire United States).

Terrell shared that commercial plans’ strategies for managing the specialty pharmacy drug spend include 3 main approaches: (1) site of care steerage (eg, benefit design, home infusion network); (2) utilization management (eg, medical policy, prior authorization, step therapy, quantity limits); and (3) clinical programs (eg, outcomes contracts, adherence goals, and quality measures). BCBSMA’s specialty network is comprised of national specialty and local provider-based pharmacies and is open to all willing providers as long as they meet predefined participation requirements based on drug access, accreditation, and oversight participation, for example. The pharmacies have performance incentives, and quarterly calls are held with each specialty pharmacy to review financial trends, operational activities, drug pipeline developments, and partnership opportunities. Quarterly dashboard reporting was added in 2019 to facilitate review of specialty medical and pharmacy prescription counts, BCBSMA liability, therapeutic category data, and drug utilization trends.

Utilization and inflation increases will continue to be the prime cost drivers in both pharmacy and medical benefits; therefore, additional strategies, such as building strong partnerships with physician and pharmacy benefit management partners, are needed in a value-based payment world. Earlier in this article, it was mentioned that the intermediaries drive cost into the supply chain system. BCBSMA is also exploring how to eliminate costs to intermediaries and possibly contract directly with manufacturers. The consumer experience is also a high priority, particularly looking at the way in which (and where) services are delivered.

To summarize, in order to manage the high cost of specialty drug therapies while ensuring quality and access, both commercial and government payers are exploring and implementing strategies to

• Monitor the specialty drug pipeline and implement proactive utilization management strategies

• Develop partnerships with provider organizations to drive alignment on preferred product selection

• Explore direct-to-manufacturer contracting for utilization and outcomes-based agreements

• Enter into risk-based agreements with pharmacies to move away from fee-for-service and toward pay for performance

• Ensure touch points that improve the patient experience, compliance, and adherence to therapies

HSSPs are well positioned to partner with payers, align with these strategies, and demonstrate value to payer stakeholders.

Conclusion

The ASHP Specialty Pharmacy State of Practice in Hospitals and Health Systems — Future Directions Summit brought together thought leaders in the industry to discuss key issues impacting specialty pharmacy practice in health systems and provide insights and strategies needed to sustain and scale the high-value services they provide. There needs to be an understanding of the current market trends that are shaping the industry, a focus on outcomes research that aligns with stakeholder objectives and demonstrates the unique value HSSPs can provide, and the development and deployment of standardized measures that support value-based payment models.

Appendix A—Summit participants and observers

Summit Participants

Paul W. Abramowitz, PharmD, ScD (Hon), FASHP

Chief Executive Officer

ASHP

Bethesda, MD

Chad Alvarez, PharmD, MBA

Senior Director of Retail Pharmacy

Carilion Clinic

Roanoke, VA

Robert J. Anderson, PharmD

Oncology Pharmacist

Tuba City Regional Health Care Corporation

Tuba City, AZ

Zinkeng Asonganyi, PharmD

Director of Ambulatory Pharmacy Services

University of Texas Medical Branch

League City, TX

Sheena Babin, PharmD

Director Clinical Services and Business Development

Ochsner Health

New Orleans, LA

Heidi Barnett, PharmD, BCACP

Director of Specialty Pharmacy

Community Health Network

Indianapolis, IN

Shubha Bhat, PharmD, MS, BCACP

Clinical Pharmacist – Gastroenterology

Cleveland Clinic

Cleveland, OH

Jerry Buller, BSPharm, MMHC

Chief Pharmacy Officer

Trellis Rx

Lebanon, TN

Paul W. Bush, PharmD, MBA, BCPS, FASHP

Vice President, Resource Development and Consulting

ASHP

Bethesda, MD

Denali Cahoon, PharmD

Chief Operating Officer

Trellis Rx

Denver, CO

Udobi Campbell, PharmD, MBA

Executive Director of Pharmacy

University of North Carolina Hospitals

Chapel Hill, NC

Scott Canfield, PharmD, CSP

Assistant Director, Clinical Program Development

Johns Hopkins Home Care Group

Baltimore, MD

Karen Y. Chin, PharmD

Director – Kaiser Permanente National Specialty Pharmacy

Kaiser Permanente

San Francisco, CA

Julia M. Chisholm, PharmD, MBA, AAHIVP

Ambulatory Operations Pharmacy Manager

University of Missouri Health Care

Columbia, MO

Kristine Crawford, PharmD

Manager, Specialty Pharmacy

Virginia Mason Franciscan Health

Seattle, WA

Charles E. Daniels, BSPharm, PhD

Chief Pharmacy Officer

University of California San Diego

Associate Dean

San Diego, CA

Stephen J. Davis, PharmD, MS, FASHP

Director, Health System Strategy

Shields Health Solutions

Houston, TX

Michael DeCoske, PharmD, BCPS, FASHP

Assistant Vice President, Ambulatory Pharmacy

Baptist Health South Florida

Miami, FL

Richard Demers, BSPharm, MS, FASHP

Chief Administrative Officer, Ambulatory Pharmacy Solutions

Penn Medicine

Philadelphia, PA

Erica Diamantides, PharmD, MHA, BCPS

Specialty Pharmacy Manager

University of Washington (UW) Medicine

Seattle, WA

Gregory Dill, PharmD

Deputy Director for Innovation and Financial Management

Centers for Medicare and Medicaid Services

Baltimore, MD

Debbie Duckworth, PharmD, CSP

Senior Director, Specialty Pharmacy & Infusion Services

University of Kentucky HealthCare

Lexington, KY

Jillian Dura, PharmD

Assistant Director, Specialty Pharmacy

Cleveland Clinic

Cleveland, OH

Letrina Flowers, CPhT

Ambulatory Medication Access Coordinator

UChicago Medicine

Chicago, IL

Jorge J. Garcia, PharmD, MS, MHA, MBA, FACHE

Assistant Vice President, Pharmacy Services

Baptist Health South Florida

Miami, FL

Christopher A. Hatwig, BSPharm, MS, FASHP

President

Apexus LLC

Colleyville, TX

Rebecca Hluhanich, PharmD, AAHIVP

Senior Clinical Pharmacist: Hepatology and Infectious Diseases

UC Davis

Sacramento, CA

Travis Hunerdosse, PharmD, MBA

Director, Specialty Pharmacy Services

Northwestern Medicine

Strategy & Business Development

Chicago, IL

Clint Ivie, PharmD, MBA, CSP

Specialty Pharmacy Manager

Intermountain Healthcare

Taylorsville, UT

Cameron S. James, PharmD, MHCI, CGP

Medical Affairs Executive Director

Genentech

Nashville, TN

Tara N. Kelley, PharmD, MMHC, CSP

Executive Director, Vanderbilt Specialty Pharmacy

Vanderbilt University Medical Center

Nashville, TN

Paul R. Krogh, PharmD, MS, BCBS

System Director – Pharmacy Services

North Memorial Health

Minneapolis, MN

Andrea Lai, PharmD

Senior Director, Ambulatory Pharmacy Services

MaineHealth

Portland, ME

James Langley, PharmD, MS

Specialty Pharmacy Manager

UW Health

Madison, WI

Dylan Lindsay, PharmD, BCACP, CDCES

Clinical Pharmacy Specialist, Specialty Pharmacy Program Accreditation and Quality Management

University of Mississippi Medical Center

Jackson, MS

Lynnae Mahaney, BSPharm, MBA, FASHP

Senior Director, Pharmacy Accreditation

ASHP

Middleton, WI

Chelsea Mouser Maier, PharmD, CSP

Specialty Pharmacy Manager

UofL Health

Louisville, KY

Lubna Mazin, PharmD

PGY-2 Health-System Pharmacy Administration and Leadership Resident

Nationwide Children’s Hospital

Columbus, OH

Alex Mersch, PharmD, MBA, BCPS

Specialty Pharmacy Manager

University of Iowa Health Care

Iowa City, IA

Kimerly M. Metcalf, CPhT-Adv

Advanced Certified Pharmacy Technician

Unity Point Health

Cedar Falls, IA

Jennifer Morris, PharmD, BCPPS, FCCM

Assistant Director of Specialty Pharmacy – Clinical Services

Texas Children’s Hospital

Clinical Pharmacy Specialist – Dialysis

Texas Children’s Hospital

Houston, TX

Mel Nelson, PharmD, CSP

Regional Manager

Fairview Pharmacy Services

Minneapolis, MN

Melissa A. Ortega, PharmD, MS, FASHP

Pharmacy Director

Tufts Medical Center

Boston, MA

Steve Pate, BSPharm

Director, Outpatient Pharmacy Services

St. Jude Children’s Research Hospital

Memphis, TN

Sunil Patel, BSPharm, MHA

Sr National Director Pharmacy Continuity of Care

Ascension Health

St. Louis, MO

Tammy Pierce, BSPharm, MBA

Executive Director, Pharmacy Services

Providence St Joseph Health/Credena Health

Portland, OR

Brian Pinto, PharmD, MBA

Senior Principal

Cigna

Baltimore, MD

Laura H. Rang, BSPharm, MPH(c)

Specialty Pharmacy Manager

Children’s Hospital Colorado

Aurora, CO

Debi Reissman, PharmD

System Senior Pharmacist Specialist

Sharp HealthCare

San Diego, CA

LaTasha R. Riddick, PharmD, BCACP

Clinical Coordinator, Specialty Pharmacy

Johns Hopkins Home Care Group, Pharmacy Services

Baltimore, MD

Matthew H. Rim, PharmD, MS

Associate Director

University of Illinois Chicago

Chicago, IL

William Roth

Founding Partner

Blue Fin Group

St. Petersburg, FL

Dalia Saleh, PharmD

Director of Specialty Pharmacy, Mail Order, Central Fill and Compounding

Advocate Aurora Health

Milwaukee, WI

Jonathan Salud, CPhT

Pharmacy Technician III

Cedars-Sinai Medical Center

Los Angeles, CA

Matthew S. Saylor, PharmD, BCOP

Medical Affairs Director – Health Systems Oncology

Merck & Co, Inc.

Charlotte, NC

Denise L. Scarpelli, PharmD

Executive Director of Ambulatory Pharmacy and Business Development

University of Chicago

Chicago, IL

Bryan Schuessler, PharmD, MS

Director of Home Infusion and Specialty Pharmacy

Saint Luke’s Health System

Kansas City, MO

Mary Beth A. Seipel, PharmD

Ambulatory Clinical Lead Pharmacist, Neurology

Truman Medical Centers

Kansas City, MO

Yenia Silva, PharmD, MBA

Director of Community and Specialty Pharmacy

Memorial Healthcare System

Hollywood, FL

Betsy Lynn Sleath, BSPharm, PhD, FAPhA

Regional Associate Dean for Eastern North Carolina

UNC Eshelman School of Pharmacy

George H. Cocolas Distinguished Professor

Chapel Hill, NC

Dele Solaru, PharmD, MBA

Chief Pharmacy Officer

US Office of Personnel Management

Washington, DC

Patrick J. Sorgen, PharmD, CSP

Specialty Pharmacy Manager

Indiana University Health

Indianapolis, IN

Brian T. Spoelhof, PharmD, BCPS, BCCCP

Assistant Manager of Pharmacy – Medication Utilization Strategy

UVA Health

Charlottesville, VA

Scott Sterrett, PharmD

Director, Home Infusion & Specialty Pharmacy

Beaumont Health

Southfield, MI

Phillip Streit, PharmD

PBM National Clinical Pharmacy Specialist for Specialty Pharmacy

Department of Veterans Affairs

Hines, IL

JoAnn Stubbings, BSPharm, MHCA

Clinical Associate Professor Emerita

University of Illinois Chicago College of Pharmacy

Chicago, IL

Robert Taketomo, PharmD, MBA

President/CEO

Ventegra, Inc., a California Benefit Corporation

Glendale, CA

Julia C. Talley, BSPharm, CSP

Specialty Pharmacy Services Manager

University of Arkansas for Medical Sciences

Little Rock, AR

Kate Taucher, PharmD, MHA, BCOP

Ambulatory Oncology Clinical Specialist, PGY2 Oncology Residency Program Director

UCHealth Memorial Hospital

Medical Key Account Manager

G1 Therapeutics

Colorado Springs, CO

Karen C Thomas, PharmD, PhD

Pharmacy Supervisor

University of Utah Health

Salt Lake City, UT

Allison C. Trawinski, PharmD, MBA

Assistant Director of Specialty Pharmacy

UR Medicine – Strong Memorial Hospital

Residency Director for PGY1 Community and PGY2 Spec Admin and Leadership

Rochester, NY

Brantley M. Underwood, PharmD, MBA, CSP

Outpatient/Specialty Pharmacy Manager

Cookeville Regional Medical Center

Cookeville, TN

Robin Wanous-Williamson, RN, GERO-BC

Director of Pharmacy Program Development

Avera McKennan Hospital & University Health Center

Sioux Falls, SD

Angela Ward, BSPharm, MSB, FACHE

SVP – Specialty Services

AmerisourceBergen

Carrollton, TX

Timothy Weber, BSPharm, MBA

System Executive Director, Pharmacy

UNC Health

Durham, NC

Ian Willoughby, PharmD, MS, BCPS

Manager, Specialty Pharmacy Services

Lifespan Pharmacy

Providence, RI

Jennifer Young, PharmD, BCPS, CSP

Program Director II

Wake Forest Baptist Health

Winston Salem, NC

Autumn D. Zuckerman, PharmD, BCPS, AAHIVP, CSP

Program Director, Health Outcomes and Research

Vanderbilt University Medical Center

Nashville, TN

Summit Observers

Leigh A. Briscoe-Dwyer, PharmD, BCPS, FASHP

System Director of Pharmacy

United Health Services

Johnson City, NY

Kathryn Edwards

Marketing Director

Trellis Rx

Atlanta, GA

Amanda Fadden

Vice President, Service Quality Excellence

Trellis Rx

Minneapolis, MN

Toni Fera, PharmD

Senior Healthcare Consultant

Independent

Pittsburgh, PA

Barry C. Fuchs, PharmD, MBA, CSP

Vice President/General Manager

Trellis Rx

Minneapolis, MN

Erin C. Hendrick, PharmD, MS, FASHP

SVP, Health System Strategy

Shields Health Solutions

Atlanta, GA

Christine Hollenberg, MHA, CPHQ

Senior Director

AmerisourceBergen

Houston, TX

Thomas J. Johnson, PharmD, MBA, BCCCP, BCPS, FASHP, FCCM

Assistant Vice President – Hospital Pharmacy

Avera Health

Sioux Falls, SD

Jacob Jolly, PharmD, MMHC, CSP

Principal Consultant

Blue Fin Group

Nashville, TN

Christene M. Jolowsky, BSPharm, MS, FASHP

Senior Director of Pharmacy

Hennepin Healthcare

Minneapolis, MN

Nishaminy Kasbekar, PharmD, FASHP

Chief Pharmacy Officer

Penn Presbyterian Medical Center

Philadelphia, PA

Katie McMillen, PharmD, MPH, FACHE

Vice President

AmerisourceBergen

Carrollton, TX

Brandon Jay Newman, PharmD, MMHC, CSP

Vice President, Clinical Affairs

Trellis Rx

Atlanta, GA

Kathleen S. Pawlicki, BSPharm, MS, FASHP

Immediate Past President

ASHP

Royal Oak, MI

Andy Pulvermacher, PharmD

Senior Principal Consultant

Blue Fin Group

Madison, WI

Jeff Romano, BSPharm

VP Operations and Site Execution

Trellis Rx

Atlanta, GA

John Ryan, BSPharm

Vice President Service Solutions and Operations

AmerisourceBergen

Hopkinton, MA

Robert Scholz, MS, MBA

Senior Director, Acentrus Specialty

Vizient

Deerfield Beach, FL

Neil Smiley

Founder and CEO

Loopback Analytics

Dallas, TX

Cedric A. Terrell, PharmD, MHA

Chief Pharmacy Officer

Blue Cross Blue Shield of Massachusetts

VP Health & Medical Management

Boston, MA

Karen Tsai

Principle Strategy Manager

Genentech

South San Francisco, CA

Paul C. Walker, PharmD, FASHP

Clinical Professor and Assistant Dean, Experiential Education and Community Engagement

The University of Michigan College of Pharmacy

Ann Arbor, MI

Casey H. White, PharmD, MBA, BCCCP, BCNSP, BCPS, FASHP

Director of Pharmacy

Cookeville Regional Medical Center

Cookeville, TN

George Zula, BSPharm, MBA, CSP

Vice President, Acentrus Specialty

Apexus

Irving, TX

Footnotes

Acknowledgments

Contract writer and consultant Toni Fera, PharmD, is acknowledged for drafting the manuscript of this article. She in turn acknowledges and thanks the authors of a series of 10 AJHP articles reporting the proceedings of the March 2014 ASHP–ASHP Foundation Ambulatory Care Summit (Am J Health-Syst Pharm. 2014;71:1345-1420), to which she referred for editorial guidance during manuscript preparation.

Disclosures

The authors have declared no potential conflicts of interest.

References