Payer Solutions for Managing High-Cost Specialty Medications

In response to the rising cost of specialty medications, which now account for 55% of total US drug spending, payers are refining their patient engagement strategies to prioritize personalized care. This payer solution aligns with the “Triple Aim” of healthcare, a key strategy developed by the Institute for Healthcare Improvement (IHI) in 2008, aimed at achieving improved health outcomes, better patient care and lower costs.

To achieve these goals, both government and commercial payers are investing in care management and clinical programs that emphasize patient-centric care. By integrating timely outreach, clinical support, patient assistance programs and personal guidance, these initiatives streamline access to therapy and enhance outcomes for managing complex, chronic conditions.

A growing number of payers are relying on AscellaHealth’s Patient Care Teams (PCTs) to implement these programs, valuing the collaborative approach that serves to fortify the healthcare patient journey. These multidisciplinary PCTs, comprised of pharmacists, team managers and Patient Care Coordinators (PCCs), facilitate seamless therapy management and provide concierge-level care that supports therapy onboarding and advances customized clinical protocols.

With a focus on whole-person health, PCCs communicate frequently with patients and families, resulting in better care coordination, smooth transitions among specialty providers and streamlined care from various healthcare specialists.

Dedicated PCCs build strong, personal relationships with patients and enhance healthcare providers’ efforts by offering continuous, direct educational support that informs treatment decisions, enriches the overall patient experience and boosts patient satisfaction.

By leveraging our secure technology platforms, PCCs provide tailored care management and support. This technology enables real-time, bi-directional communication, significantly enhancing patient engagement, improving medication adherence and ultimately driving the best possible therapeutic outcomes.

Medical Cost Management

A growing body of evidence validates that patients who are better engaged and more actively involved in their healthcare decisions experience better health outcomes and incur lower costs. 

In a large randomized study, medical costs were 5.3 percent lower for patients receiving enhanced decision-making support versus those who only received minimum support, and they also experienced 12.5 percent fewer hospital admissions and 20.9 percent fewer heart surgeries. Engaged patients can see up to 6 times better health outcomes than their less-engaged counterparts, reducing the need for costly interventions and improving long-term health. Informed decision-making extends the benefits of patient engagement to broader populations, driving better care and more sustainable healthcare systems.

Emphasis on Patient-Centric Care

As open enrollment season gets underway, health plans are implementing benefit design changes to address medical cost management and provide patient-centric care that is tied to clinical outcomes. The Institute of Medicine describes patient-centered care as, “including qualities of compassion, empathy, respect and responsiveness to the needs, values, and expressed desires of each individual patient.” In patient-centered care models, the individual needs of each patient and the desired health outcomes are the driving force behind all clinical care decisions.

Experts advise that patient-centered care isn't a "nice to have"; it's a "need to have," providing a more holistic approach that is inclusive of families and caregivers, significant others and healthcare preferences, among other elements.

AscellaHealth fully embraces the model of inclusive, patient-centered care, where patient values guide every clinical decision. Our innovative payer solutions have proven effective in increasing access to lifesaving medications and enriching the overall patient journey. By integrating our patient-first philosophy with a commitment to personalized care, we address the multifaceted needs of our patients, resulting in improved health outcomes and a more supportive care experience.

Our PCCs are keenly aware of the anxiety and fear that patients sometimes experience when undergoing specialized treatments, such as infusion therapies. They are adept at bridging the communication gaps that exist between patients and healthcare providers. Most importantly, they make it a priority to comfort and reassure their patients at every step along the treatment journey – from onboarding activities and coordinating insurance coverage to addressing adverse or unexpected events resulting from treatments.

PCCs also introduce patients to financial support solutions that help them access assistance programs designed to make medicines more affordable, enhance medication access and increase medication adherence. For patients who do not qualify for insurance, patient assistance programs (PAPs) provide free or low-cost medications to low-income individuals. Co-pay assistance programs also reduce out-of-pocket expenses that insured patients must pay, helping patients manage financial burdens and accelerate access to treatments.

AscellaHealth is recognized as a leader in delivering customized, patient-centric programs through our specialty pharmacy and distribution center. Our unique approach integrates cutting-edge technology with high-touch service, addressing not only physical health but also the emotional, social, and financial aspects of patient care. This synergy allows our PCCs and teams to deliver exceptional, personalized care. By leveraging secure technology platforms, we enable real-time communication and tailored care management, which supports payers in enhancing patient experiences and implementing payer solutions that address rising costs while improving health outcomes.

Stay Connected

Join AscellaHealth in Observing Gene Therapy and Specialty Pharmacy Awareness Month, September 2024.

This annual observance, established by AscellaHealth, is included in the annual Calendar of Health Observances & Recognition Days, published by The Society for Health Care Strategy & Market Development (SHSMD) of the American Hospital Association. We invite all industry stakeholders to participate alongside AscellaHealth to:

• Highlight the importance of patient-centric care and collaborative opportunities that help optimize therapeutic outcomes and enhance the quality of life for patients with chronic conditions.
• Draw attention to the valuable role of specialty pharmacies and their focus on high cost, high touch medication therapy for patients with complex disease states.
• Raise awareness of the opportunities for collaboration among manufacturers of specialty pharmaceuticals as well as government and commercial payers to improve patient access to therapy.

Read our latest Payer Insights article, “Infusion Therapy Site of Care Optimization: Quality & Economics”.

For more information, please contact AscellaHealth or email businessdevelopment@ascellahealth.com.