Realizing the goal of high-quality care and controlled costs
Executive Summary
This content was written by Excelera, a Shields company.
Excelera was engaged to lead the development of the Avera Specialty Pharmacy service and pharmacy operation to develop an integrated specialty pharmacy delivery model that leveraged the health system EMR, help them gain access to specialty drugs, and compete with large national specialty pharmacies.
The engagement was comprised of providing advisory, project management and subject-matter expertise and assistance for the specialty pharmacy design, build in and implementation including related pharmacy support operations, (e.g. call center, revenue cycle and business office functions). The goals of the engagement were:
- Conduct a gaps analysis of all specialty pharmacy business and operations;
- Establish and implement best practice clinical therapy management programs;
- Develop data collection and aggregation processes and procedures; and,
- Prepare the organization for URAC accreditation
Challenges
In an era of organizations moving toward Accountable Care Organizations, Avera Health sought a consultant to guide and assist them with their objectives to build a specialty pharmacy delivering high-quality care while controlling costs.
How Excelera helped
The engagement included the coordination of planning, development and implementation support for:
- Gap analysis
- Overall Project Plan
- Specialty Pharmacy Build-out
- Clinical Therapy Management
- Call Center/Pre-Authorization and Financial Assistance
- Revenue Cycle: licensing, credentialing, billing and revenue integrity, finance and accounting, audit defense, payer relations, 340B program
- Job Descriptions & Human Resource Planning: staffing models and training process
- IT: decision support for: case management software, phone and reporting systems; connectivity to Excelera data aggregation system
- Compliance, Quality, Regulatory, P&P Plans: including URAC accreditation support
- Provider Integration: targeting, measurement, best practices
Results
Avera Specialty Pharmacy opened and began filling prescriptions in 2014. The engagement with Excelera completed on time and on budget, and has allowed Avera Health to realize their goal of high-quality care and controlled costs much more expeditiously than they could have going it alone. Today, Avera Specialty Pharmacy fills 2,600 prescriptions per month, of which almost half are specialty, provides pharmacy care of chronic, rare or complex conditions that require specialty medications across 17 or more disease states and is an active, collaborative member of the Excelera national specialty pharmacy network.
