January 2024

2023 was a landmark year for specialty drug approvals. How will the payors respond in 2024? And what do you need to do to gain or improve your specialty network access? The answers to those questions and more are in today's expert Q&A with payor expert, John Luebker. His specialty? Specialty pharmacy.

Before joining us to lead our payor strategy team, he spent nearly two decades supporting managed care and payor relations for several major retailers. Today, he's helping specialty pharmacies, hospitals, and payors work better so patients can live better. Here's an excerpt of our conversation.

CPS: John, hello and welcome in! Everyone's eager to hear about what's happening with the payors this year. Before we do that, tell us more about yourself. What makes you excited about what you do?

JOHN LUEBKER: It's great to be here! Well, I'm certainly excited to talk about what we're hearing from the payors and how it impacts the pharmacy landscape.

"Helping people through pharmacy hits close to home. There are multiple generations of pharmacists in my family, and a century's worth of experience between us all!"

Growing up so close to the profession, I've always wanted to help people find a better quality of life through my work.

CPS: Wow! A century of pharmacy experience in your family? That's really special. No wonder bringing everyone together is such a personal mission for you.

LUEBKER: Indeed! It always makes for some interesting conversations around the table during the holidays.

CPS: I bet! What was on everyone's minds this year?

LUEBKER: Where to begin?! Well, 2023 was a landmark year for specialty drug approvals, especially in oncology. (If you're looking for a great article about that, my colleague, Susan Trieu, recently sat down with Specialty Pharmacy Continuum to tell people what to expect. It's a great read!)

"2023 was a landmark year for specialty drug approvals. Everyone is wondering how the payors will respond.

Everyone is wondering how the payors will respond.

Many people are questioning how limited distribution drug (LDD) network access may be impacted. Historically, there's been a lot of competition to gain formulary access and as these new specialty drugs come to market, things may get more intense.

We also continue to hear many questions about the differences between the pharmacy and the medical benefit, too.

CPS: Interesting! Could you tell us more about that?

LUEBKER: We're seeing many hospitals interested in exploring the benefits of building and growing their own wholly-owned specialty pharmacies to better serve patients and communities. However, many can face barriers and lockouts when trying to gain formulary access, particularly if a payor has a specialty pharmacy. That can make it tough to launch and grow a health system specialty pharmacy if you don't have the right support.

"If you don't have the right support, it can be tough to gain the network access needed to launch and grow a health system specialty pharmacy."

CPS: I bet! Could you tell us more about the questions people are asking when it comes to the differences between the medical and pharmacy benefit?

LUEBKER: Yes, the pharmacy benefit is quite different than the medical benefit that many clinicians know well. 

Many leaders are accustomed to working with payors via the traditional medical benefit model. They may not yet realize that there is a different way things are done in pharmacy, which can lead to missed expectations for everyone.

"It takes a whole new set of skills to gain access to the exclusive LDD networks and their specialty therapies."

For example, if you have more experience with the medical benefit, you're used to infusibles, HCPC/J-codes, and more traditional billing practices covered by the medical contract. However, the pharmacy benefit is on a pharmacy contract. This usually requires credentialing for specialty network access. should expect real-time adjudication processes and to be working with self-injectibles and oral solids, for example.

Often, people can feel caught off guard when they hear about what's needed for specialty credentialing and ongoing reporting. That's why we're eager to help anyone who might need it.

CPS: A very worthy mission, indeed. What do you feel like people need to know this year?

LUEBKER: Things might get even more challenging in 2024 as the payors continue vertically integrating. Restrictions may get tighter, and policies may change as the health plans consolidate.

Specialty pharmacy leaders need to be planning today for the changes that are likely to come tomorrow.

Some health plans and PBMs are also interested in creating health system specialty networks. We will have at least three larger to mid-sized national plans by the end of next year, but they are looking for partners to streamline this work for them. Hospitals would be wise to keep an eye on these trends.

CPS: What can hospital pharmacy leaders do to nurture better payor relationships?

LUEBKER: The PBMs and health insurance companies aren’t actively looking to add new partners, so you must give them every reason to put you into the network. Hospitals and health systems that can demonstrate how their specialty pharmacies are driving positive outcomes for high-cost and specialty medications get better LDD access. 

"Give the payors a reason to call you back. Why should they let you in?"

Here's what makes a difference: Data. It helps tremendously if you can show the pharmacy is driving positive patient outcomes and that patients are adhering to medications and treatment plans and progressing well.

Moreover, you should demonstrate how the specialty pharmacy is reducing readmissions and supporting better care transitions. To compete, you must be ready to show what you're doing in the marketplace and prove your value.

Your responsibility is to demonstrate the value you provide to payors. If you can do that successfully, your organization wins.

CPS: Very wise advice. Do you have any parting advice for readers?

LUEBKER: Clinical outcomes benchmarking is critical. Make sure you have the technology to help you generate the analytics and detailed clinical reporting you'll need to show specialty pharmacy value. The right tools and partners can help you do this well and keep up with ongoing payor demands.

Also, if people want to learn more, I recommend this in-depth guide for gaining access to payor networks.

If this resonates with you, we'd welcome the opportunity to learn more about how we can help your hospital overcome your unique payor access challenges.

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