Surveying The Specialty Drug Management Landscape

Medical Specialty Drug management landscape – Providing a healthy environment for [Pharma] innovation and [CMS] scale to flourish.

RJ Health occupies a “crossroads” piece of real estate within the Specialty Drug landscape

– or, think of us as a reimbursement compass where the needle is pointing to the proper reimbursement rate for drug therapies that treat hemophilia, Crohn’s disease, multiple sclerosis, cancer, and dozens of other life-changing diseases.  We consider our lot in life to be privileged (we have a front-row seat to drug innovation and availability in the US market, which makes up nearly half of global drug sales of ~$800 billion), but also purposefully mundane (a front-row seat to legacy systems that manage nearly half of the US’ $3.3-trillion healthcare spend).

Our role is to navigate large volumes of data from the two major market centers:

(i) Pharmaceutical Manufacturers (Pharma) on one coast and

(ii) the Centers for Medicare & Medicaid (CMS) on the other coast(note, the FDA supports the process of course, but in the backseat for the innovation and sustainability journeys)

And supporting these two major centers of influence are stakeholders that add-value and useful, discreet slices of data – like this map:

RJ Health Specialty Drug Management Landscape

What we see is a very productive relationship between CMS and Pharma, each maintaining their own value chains in “self-serving”, competitive directions.  The former to achieve quality care for the largest swath of the US population… the latter to profitably relieve the burden on society of chronic and deadly diseases.

The unifying force is achieving coherent drug data from & for CMS, Pharma, Payors, Network operators, Providers, and Processing partners.  Data coherence leads to less friction, greater control, and a lower variable cost on Specialty drugs, which profits everyone…

To add dimension to the map, it is helpful to consider the main themes for each of the value-creating stakeholders in the Medical Specialty Drug landscape:

CMS – Balance healthier populations with fiscal sustainability.

Pharma – Balance innovation and profits with healthier populations.

Payors – Spread the risk of Specialty Drug populations (and drug costs) across the general membership.

Network – Achieve access, quality care, consistency and fast, accurate reimbursement.

Processing Partners – Achieve scale and/or efficiencies.

And finally, the Patient – Lest we ever forget the lives that can be improved when we navigate the data successfully to ensure therapy access, fast and appropriate payment for high-cost drug therapies with huge societal impact…

With these dynamic, oftentimes fragmented stakeholders adding value towards a healthier environment for innovation and scale, someone is required do the detail work of normalizing innovation for large-scale commerce.  But we are in the pioneering days of accessing quality data from all those with a “pin on the map” – it’s usually not a question of sourcing the data, it’s about removing the silos to capture a horizontal view of the patient, care designs and therapies from EHR, Prior Authorization, Claims, Contracting, and Financial systems.

Let us know how your Medical Specialty drug data journey is going…  We would love to explore our data combined with yours, or send you timely insights and analysis…

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