In this episode, Ameet Wattamwar, Director of Health Systems Strategy at Shields Health Solutions, discusses the role of specialty pharmacy and improving patient outcomes.
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Learn how to listen to The Hospital Finance Podcast® on your mobile device.Highlights of this episode include:
- Shields Health Solutions background
- Benefits of the integrated specialty pharmacy model
- Examples of why a patient might experience a hospital readmission
- Patients who would be considered at a higher risk of readmission
- Shields’ integrated care model impact
- Highlight of outcomes
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome Ameet Wattamwar. Ameet is a nationally recognized leader in specialty pharmacy strategy. At Shields Health Solutions, he serves as the Director of Health Systems Strategy, leading initiatives focused on strategy, partnering with U.S. hospitals and health systems to design, optimize, and scale integrated specialty pharmacy programs that improve patient outcomes and drive financial growth. Previously, Ameet served as the Director of Specialty Pharmacy at NYU Langone Health, where he helped build the Health System Specialty Pharmacy Service Line. Prior to that role, he was Vice President of Client Strategies at AmerisourceBergen Pharmacy Healthcare Solutions, advising health systems on 340B optimization, ambulatory pharmacy expansion, and operational performance. With a career spanning clinical practice, consulting, and strategic leadership, Ameet brings a comprehensive perspective on the pharmacy value chain, from frontline care to executive-level strategy. He is passionate about improving access to care, eliminating system fragmentation, and advancing sustainable innovation in the specialty pharmacy space. In this episode, we are discussing the role of specialty pharmacy and improving patient outcomes. Welcome, and thank you so much for joining us, Ameet.
Ameet Wattamwar: Hi, Kelly. Thanks for inviting me. Happy to be here.
Kelly: Awesome. Well, let’s go ahead and jump in. So can you provide some background on Shield Health Solutions and the benefits of the integrated specialty pharmacy model?
Ameet: Sure. Absolutely. So, Shield Health Solutions collaborates with approximately 80 health systems nationwide, representing about 1,200 hospitals. And I actually represent a former customer having built the NYU Langone Health Systems Specialty Pharmacy Program in partnership with Shields going back to about 2016, when I led the Health Systems Specialty Pharmacy Service Line. And in terms of the concept, I think Shields was built on the benefits of an integrated specialty pharmacy model, which means a specialty pharmacy that is embedded as part of the health system. And oftentimes it’s on site at the health system, but it doesn’t necessarily need to be. And I think with an integrated specialty pharmacy model, healthcare providers and in clinic staff are able to play a much more active role in the patient’s pharmaceutical care journey. And this means the patients have active support in getting started on their therapy and staying on their therapy. And any necessary adjustments to the patient’s care, such as dose changes or treatment changes or any concerns around the patient that they may have around their drug, they’re addressed much faster and more effectively. And I think critical to an integrated specialty pharmacy model, I guess the backbone that facilitates this high touch care program is access to the electronic medical record. And I think, again, it really differentiates an integrated program from one that’s not because the EMR enables real-time, up-to-date clinical and laboratory information, which arms the pharmacy care team with everything that they need to most effectively manage the patient in a proactive way and ensure that the care is coordinated with tight communication, which is essential for success.
Kelly: Wonderful. Thank you so much for providing that background for us and the benefits of the model. So, we know hospital readmissions have been a major issue for health systems as they are extremely costly and directly impact patient outcomes. Can you give us an example of why a patient might experience a hospital readmission after they’ve been discharged to their home?
Ameet: So that’s a great question, Kelly. And I think hospital readmissions frequently occur due to a combination of factors, including social determinants of health, such as a lack of transportation, limited financial resources, and an inadequate social support system. I also think medication non-adherence is paramount, and that could be for a number of reasons. It could be driven by the complexity of the regimen itself, unaffordability, which could exacerbate underlying medical conditions when medications are not taken. Additionally, errors just in medication administration or prescribing can lead to clinical deterioration, ultimately resulting in readmission. But when we talk about medication management, I often use the analogy of a leaky bucket to help illustrate the challenges that patients face when specifically focusing on the adherence issue and how that contributes to ED readmissions. And I’ll just say I’m not sure exactly who came up with the leaky bucket metaphor. Might have been a former mentor of mine, Matt Wolf, so I’ll give him credit here. But imagine we start with a bucket full of water, representing 100% of the patients who were initially prescribed a medication. And as we move through each step of the patient’s journey, or each of five leaky buckets, you’ll see where the leaks occur, gradually losing patients until only a fraction remain consistently adherent to their prescribed medication regimen. So, when we start at bucket one, this is when patients are initiated on a therapy. And again, we started 100% of patients who are prescribed the therapy. But right off the bat, 20% of patients actually never initiate that therapy. And that first leak often happens just due to denied prior authorizations or high patient out-of-pocket costs or other insurance coverage issues or logistical challenges.
So now you’re at 80% of patients. As you move from bucket two to bucket three, we’re now looking at successfully filling the first prescription. And of the 80% who actually have the medication initiated, like sent to the pharmacy, another 15% never fill that first prescription. And again, other issues, a lot of administrative barriers. It’s complex or confusing pharmacy processes. There’s communication breakdown between the provider and the pharmacy, financial toxicity again, or just the lack of patient education, right? So now you are down to 65% of patients. If you go from bucket three to four our continuation beyond the first fill, among the 65% who fill their first prescription, we then lose another 15% who fail to continue the treatment. A lot of the same issues, but other issues could now include there could be side effects, tolerability issues, or a perceived lack of immediate efficacy, or against a poor understanding of the importance of continued treatment. So now you are at 50% of your patients. And as you go from bucket four to bucket five, we’re now looking at medium-term adherence or adherence for three to six months. And at this benchmark, we tend to lose another 10% for many of the same issues. Or also in addition to that, just a lack of a coordinated process to follow up with patients, just refill reminders, or actually getting the medication into the patient’s hand. You’re left with 40%. And in the final bucket, we’re defining long-term adherence beyond 12 months.
Only about 30% of patients who were originally prescribed a specialty medication are still adherent at the one-year mark, right? And so that means 70% of patients have fallen off therapy along the way. This results in poorer clinical outcomes and oftentimes higher healthcare utilization, actually expenses, which includes ER visits and hospital readmissions. So really to address this, Shields has taken, I think, a systematic approach in terms of closing these gaps. And we do this in a number of different ways. But going back to what I had said about the EMR, when Shields partners with the health system, our pharmacists are able to access the wealth of information in the EMR, and then we use proprietary data analytics to risk stratify every single patient for the purposes of developing a customized care plan and a suggested cadence for communication between the patient and the pharmacist. This is incredibly powerful. Patients are engaged and you have someone specifically dedicating their time to optimizing pharmacotherapy. We then marry this high touch pharmacist driven clinical care model with a white glove concierge service, also known as our Shields Pharmacy liaison. And this is a dedicated person. Typically, it’s an exceptional pharmacy technician by background who’s dedicated and assigned to every patient.
They know each other on a first name basis. And this liaison’s job is to eliminate all of those administrative burdens that we just outlined, which are typically associated with getting started on a specialty medication and staying on a specialty medication. So, by that, I’m specifically referring to executing prior authorizations quickly and proactively enrolling patients into financial assistance programs to eliminate financial toxicity, in addition to just general care coordination, which could mean so many different things. But I think, simply put, the outcome of this type of integrated model is a happier and a healthier patient, which oftentimes means happy clinicians. And we probably don’t have time to cover all of this, but I think having access to your own patient tends to be the biggest barrier for health systems who would love for nothing more than to deliver an integrated comprehensive care model just like this. But Kelly, as you know, it’s no secret that the pharmacy world is a vertically integrated environment where payers restrict hospitals from providing pharmacotherapy to their own patients because those payers would like to fill their prescription in the PBM owned pharmacy. And ironically, this forces the patients that need health system pharmacotherapy care management the most into an option which is just inferior. Again, because of the lack of access to the EMR or proximity to the patient and providers.
Kelly: Wow, I mean, hearing that story, the buckets, I love that and such a good explanation of hospital admissions and why it is so important. Are there any patients who would be considered at a higher risk of readmission? If so, why?
Ameet: Yeah, certainly. I think patients with chronic and complex diseases, particularly those requiring specialty medications, are notably at a higher risk of hospital readmissions. If you think about conditions such as cancer, multiple sclerosis, rheumatoid arthritis, HIV… they entail intricate treatment regimens that require vigilant medication management. Socioeconomic challenges compound these risks, making adherence to prescribed medications difficult, further increasing vulnerability to readmission for these populations.
Kelly: No, that makes a lot of sense. How does Shields integrated care model impact outcomes and risk of readmissions for these patients?
Ameet: Yeah, absolutely. I think long story short and in a very meaningful and a positive way, Shields integrated care models significantly mitigates the risk of hospital readmissions through intensive pharmacist led patient interventions integrated directly within the health systems EMR like we just discussed, right? And our pharmacists complete comprehensive medication reviews and proactively identify issues like drug interactions, adherence barriers, and side effects. So, for example, in 2024, Shields Clinical Pharmacist completed over 67,000 targeted interventions with a 97.8 acceptance percentage by the provider that prescribed the medication. And that’s such a staggering number. That means in 2024, there were over 65,000 unique instances where a Shields pharmacist made a suggestion that was accepted by the doctor who prescribed the medication, right? And this intervention fundamentally alters the trajectory of the patient’s care and directly impacts their health outcomes, which again can tie back to overall healthcare expense and a reduction in ED utilization.
And specifically, Shields’s model has notably reduced ED utilization among oncology patients, and we’re able to see that, right? Objectively. Nationally, approximately 44% of cancer patients visit the ED within one year of diagnosis due to a disease-related complication or treatment side effect. And in stark contrast, only 4.9% of oncology patients within the Shields Health Network reported a hospital or ED utilization, right, specifically within the cancer diagnosis. And I think this illustrates the effectiveness of proactive clinical monitoring, timely interventions, and comprehensive patient support. And the last thing I’ll say, I really was blown away by some of the data. In 2019, a study was completed by Optum Analytics, which demonstrated that Shields’s integrated pharmacy model effectively reduced total healthcare costs per patient by 13%, which is staggering. And the study analyzed Medicare Advantage patients who had filled at least one specialty prescriptions, comparing against patients that were enrolled in Shields care model versus a national control group. And so the risk adjusted per member per month cost dropped significantly for those receiving this fully integrated pharmacy care model.
Kelly: Wow, that is impressive and fantastic. Can you highlight some of the outcomes you all have achieved that could have a direct impact on lowering the risk of a hospital readmission?
Ameet: Yeah, absolutely. So, in addition to what we just mentioned in terms of like how we’re able to see the care model meaningfully improving outcomes, there’s just a number of other data points that we tend to track. And across the board where we look at the data, we can see that patients are just, again, objectively doing better. And so, for example, our multiple sclerosis patients reported an annualized relapse rate or an ARR of 0.21. That’s significantly below the optimal target of less than 0.37. And in fact, I think that ARR of 0.21 is better than the outcome which got the medication approved as part of the FDA trial. And similarly, in RA, for example, within our integrated model, our patients achieved a medication adherence rate of 92%, leading to fewer disease flare-ups and hospitalization. But to achieve that, there’s a ton of work that goes into providing care for the patient. And our clinical team just does a phenomenal job. And so, for example, in RA, in terms of staying engaged with the patient, our pharmacists complete three rapid assessments with each RA patient. And if we find that a patient doesn’t feel great or isn’t seeing the symptomatic improvement that was expected, then our pharmacists will actually proactively engage the prescriber and they’ll likely suggest an alternative therapy or a complementary therapy or just some kind of change so we can see the outcome that was expected, right?
And I think that’s the level of care that’s required because if you don’t create that intervention and you ask the patient to continue to take the medication, which they don’t think is working, the odds of that patient being adherent to their therapy, it drops dramatically. So, by staying ahead of it, by identifying the issues and root causes and proactively changing the care regimen on an as needed basis, I think you’re really setting the patient up for success. And in other disease states as well. For example, in HIV, medication adherence rates for Shields patients, it’s about 95%, right? And that reflects an enhanced disease control, reduced complications, and a reduction in hospitalization. And ultimately, in addition to the, I guess, these exceptional clinical outcomes, we’re also seeing that patients just really enjoy having this level of support. And we can see that in our net promoter score. And when it was last measured, it was 84% nationally. That is incredible, right? If you think about companies like Amazon, they’re nowhere near 84% and everyone uses Amazon for everything. And so, I think that really just goes to show how much patients and providers appreciate this level of care and support.
Kelly: Sure, that’s impressive. And you should tout that. That’s very awesome. So, specialty drugs can be extremely costly for patients. Can you explain how Shields helps to drive down these costs to impact both patients and health systems?
Ameet: Yeah, absolutely. And you’re absolutely correct, right? These medications are really expensive, but they’re lifesaving therapies. And so, it puts patients in a really tough situation. And I heard this story recently, just it literally broke my heart. There was a mother who had two children with cancer. She couldn’t afford the co-pay for both children, so she would alternate. In the first month, she would give her first child the medication, and the second child wouldn’t get it, and then they would switch. And the next month, the other child would get their cancer medication. I mean, we cannot live in a world where that is acceptable. And I think Shields is cognizant of that and has proactively created workflows which have significantly lowered patients out of pocket costs, effectively eliminating unaffordability issues as a barrier for treatment. And so, what we typically do is when a patient is prescribed the medication, regardless of where that medication is going to be filled, the liaison will first complete the prior authorization, the benefits verification.
But again, as I mentioned, they will then be able to confirm exactly what the patient’s out-of-pocket cost will be. If that out-of-pocket cost is above $10 for any reason, we will then proactively enroll that patient into any kind of copay assistance program which is available to them. So, for some patients, that could be manufacturer sponsored copay assistance programs, but for patients on Medicare or Medicaid, for example, they’re not eligible. So, then our team really does a great job of understanding other options available in the market. That could be charities, grants, foundations, and this changes regionally, right? State by state, nationally. And so, it requires a lot of local understanding of resources that are available. But our team is so good at identifying that and enrolling patients. And despite the high costs for these medications, Shields’ patient average copay is about $8 to $14, which is just so great to see that because again, cost typically is not going to be a barrier for patients.
Kelly: I love that. I mean, really, what you guys are doing for patients is just fantastic. I know from personal experience, those can be very costly. Well, we really appreciate you sharing your insights with us today, Ameet, on the role of specialty pharmacy and improving patient outcomes. If a listener wants to learn more or contact you to discuss this topic further, how fast can they do that?
Ameet: The easiest way to contact Shields is you can go through our website and there’s some information that you can provide and someone would be able to get a hold of you pretty quickly. Or you can find me on LinkedIn. I’m on there and I would be more than happy to personally direct you to the most appropriate person at any time.
Kelly: Great. Thank you for providing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…
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