Specialty Pharmacy Continuity is Lost When PBMs Steer Patients: Brooke Looney, PharmD, CSP

Patient choice of pharmacy, rather than steering by a pharmacy benefit manager (PBM), is the piece of Tennessee's Freedom, Access, and Integrity in Registered Pharmacy (FAIR Rx) Act with the most direct consequences at the pharmacy level, according to Brooke Looney, PharmD, CSP, a specialty pharmacist at Vanderbilt Specialty Pharmacy in Nashville.

She said she has not felt any effects in day-to-day practice yet, and she does not have a clear read on where the law stands.

Why Pharmacy Choice Affects Continuity of Care

Institution-based specialty pharmacies and medically integrated pharmacies deliver better continuity of care, Looney said, and the mechanics explain why. Her team has access to the medical record, completes prior authorizations, turns drugs around quickly, and can monitor patients afterward, with several built-in programs ensuring follow-up. When patients are forced to use an outside pharmacy, that value is lost.

Looney said she hopes the relevant provisions hold. She also pointed to pricing transparency as a potential benefit, specifically transparency into why patients are being driven toward particular pharmacies.

Which Cost-Saving Strategies Have Been Shown to Work

Looney noted that dose-rounding strategies are important for cost savings. For weight-based infused drugs produced in single vial sizes, pharmacists have authority to round to the nearest vial size when dosing falls within 10% of the range, an approach that has generated substantial savings across multiple institutions and academic medical centers.

Her practice implemented a second strategy for oral oncology renewals. Rather than forwarding requests straight to the provider, specialty pharmacists review them against the patient's upcoming appointments to see whether scans or lab work are due. They also check whether the patient has had adverse effects, whether a dose change is likely at the next visit, and how much medication is on hand, which is visible because prescriptions are filled through the in-house specialty pharmacy; renewals are held until after that appointment.

Across a 1-year look-back, Looney said initiatives such as holding a 30-day supply for a patient with an appointment 2 days out, someone who might not need a full refill or might be switching medications, produced roughly $900,000 in savings.

What Determines Whether This Is Replicable

Implementation varies by site. It was straightforward at her practice because pharmacists are embedded in the oncology clinic, work hand-in-hand with providers, and have an in-house specialty pharmacy with next-day turnaround for most patients, so refills arrive without missed doses. Other structures will differ, though, Looney said, as pharmacists have many avenues for cost savings.