Editor’s observe: This story relies on discussions at Abarca Ahead, a convention in San Juan, Puerto Rico, hosted by Abarca Well being, a pharmacy profit supervisor. MedCity Information was invited to attend the occasion. Lodging for the group had been lined by Abarca. Nonetheless, firm officers had no enter in editorial protection.
A number of years in the past, Sarah Marche, senior vice chairman of pharmacy companies at Highmark, started to query the “legacy means” well being plans had been managing specialty medicine, which was by way of unique relationships with specialty pharmacies. The concept was that the “finest solution to get one of the best value was to scale your lives and the utilization to at least one pharmacy,” she mentioned.
“I used to be continuously getting approached by different specialty pharmacies about a number of the distinctive issues that they had been doing to care for his or her sufferers that had been actually specialised on sure circumstances,” Marche mentioned. “We had oncology pharmacies taking good care of oncology sufferers otherwise, or cystic fibrosis pharmacies taking good care of these sufferers. … My reply to these pharmacies was all the time ‘I can’t work with you, as a result of I’ve an unique relationship with a pharmacy,’ and that simply began feeling like that was not the correct reply.”
She made these feedback final week throughout a panel dialogue on the Abarca Ahead convention in San Juan, Puerto Rico. She mentioned that on account of this problem, the corporate moved away from unique relationships with specialty pharmacies and started working with Free Market Well being about 5 years in the past.
By this partnership with Free Market Well being, Highmark members are matched to the specialty pharmacy that most closely fits their wants, whether or not that be well being system pharmacies, neighborhood pharmacies, these focusing on sure illness states or giant specialty pharmacies. Earlier than Free Market Well being, each single Highmark member went to the one pharmacy Highmark had an unique relationship with, whether or not or not there was a greater match for the affected person, in line with Marche.
“Once I met Joe Cardosi from Free Market Well being, he talked about this new mannequin of actually having a look at every particular person affected person and saying, ‘What’s their scientific state of affairs? What illness have they got? What comorbid circumstances have they got?’ And actually matching them up with the best-fit pharmacy for them,” Marche mentioned. “The very best-fit pharmacy might be as a result of that pharmacy is targeted on sure points of that scientific situation, and so they [have] some confirmed outcomes on how they handle that illness. Or it may simply be that it’s a robust monetary match for that member.” Cardosi is the founder and CEO of Free Market Well being.
Highmark initially rolled out this Free Market Well being partnership with its Medicaid inhabitants after which finally with its ACA and fully-insured inhabitants. In 2025, it started promoting to its self-funded inhabitants.
What Highmark hopes to show on this partnership is that by bettering affected person outcomes, medical prices will lower, Marche added.
“Having an oncology affected person that’s serviced by an oncology pharmacy, we must always see higher outcomes and on the finish of the day, these sufferers ought to be more cost effective,” she acknowledged. “So proper now, we’re engaged on, how will we show out that worth proposition?”
Nonetheless, this market mannequin doesn’t come with out challenges. But it surely’s price it to be able to create extra worth for sufferers, argued Mark Conklin, president and COO of Free Market Well being, throughout a separate presentation at Abarca Ahead.
“After we take into consideration what the choices are at present with an unique supplier, in the event you’re sort of in an open fashion community, conceptually, these are a lot less complicated,” he mentioned. “So if we’re speaking about disaggregating the mannequin of companions to construct worth, or on this case we’re going to speak a couple of new means to consider a specialty drug program — a market mannequin — there’s a resolution burden there that’s larger than what we now have to pay. However there’s additionally the chance to seize much more worth in a much more nicely orchestrated ecosystem.”
Photograph: PeopleImages, Getty Photographs
