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340B Insight provides members and supporters of 340B Health with timely updates and discussions about the 340B drug pricing program. The podcast helps listeners stay current with and learn more about 340B to help them serve their patients and communities and remain compliant. We publish new episodes twice a month, with news reports and in-depth interviews with leading health care practitioners, policy and legal experts, public policymakers, and our expert staff.
Narration [00:00:04]:
Welcome to 340B Insight from 340B Health.
David Glendinning [00:00:12]:
Hello from Washington, D.C. and welcome back to 340B Insight, the premier podcast about the 340B drug pricing program. I'm your host David Glendenning with 340B Health. Our guest for this episode is Josh Weber with St. Luke's Health System based in Boise, Idaho. The field of specialty pharmacy is a large and growing one as more providers rely on specialty drugs to treat their patients. With that growth comes opportunities for clinical pharmacists to play a key role in the pathway from the specialty drug pipeline to the patient. We wanted to speak to Josh about how health systems like St.
David Glendinning [00:00:51]:
Luke's are integrating clinical pharmacists into specialty pharmacy. But first, let's do a quick recap of some of the Latest news about 340B. The Health Resources and Services Administration has approved 340B rebate pilot program proposals for eight of the nine drug companies that applied to implement rebates starting next year. The rebates will apply to all covered entity types starting January 1, 2026. Notable provision in the approved rebate plans include that all CEs must purchase the nine affected drugs at wholesale acquisition cost on their 340B wholesaler accounts, that the rebates will be determined on a unit basis, and that drug companies may not require CES to submit purchase data. Though HRSA encourages drug makers to work with wholesalers to obtain the data, this decision by HRSA was will usher in a major change from the long standing upfront discount model that has governed 340B for more than 30 years. You can visit the show Notes to find the HRSA announcement, the drugmakers descriptions of their rebate proposals, and a full analysis for 340B Health members. And now for our feature interview with Josh Weber with Idaho's St.
David Glendinning [00:02:24]:
Luke's Health System. Josh was one of the experts appearing on a panel at the most recent 340B Coalition Conference on how covered entities can enhance their specialty pharmacy areas using clinical pharmacists. We caught up with Josh just after that presentation to hear more about what he had to say to the conference attendees. Here's that conversation.
David Glendinning [00:02:46]:
I am here with Josh Weber, who is Senior Director, Ambulatory Retail and Specialty Pharmacy Services at St. Luke's Health System. Josh, welcome to 340B Insight. Thanks for being here.
Josh Weber [00:03:00]:
Yeah, thank you for having me.
David Glendinning [00:03:02]:
We've talked about on the program before the role of clinical pharmacists. We've talked about specialty pharmacy, but we've never actually talked about the marriage of the two. So that's what we're going to be chatting about here today. But before we get to that, please tell us a little bit about St. Luke's and the patients you serve there.
Josh Weber [00:03:21]:
So St. Luke's is the only Idaho based, not for profit, community owned and community led health system. Our mission is to improve the health of people of the communities we serve in southern and central Idaho, eastern Oregon and northern Nevada. We operate eight 340B covered entities. So two of them are DISH hospitals, one's so community community health center, four critical access hospitals and then one hemophilia treatment center. We dispense over 800,000ambulatory dispenses annually. That's across our specialty home delivery and retail lines and serve about 25,000 patient lives. So we're the state's only children's hospital offering specialized pediatric care including at level 2 on pediatric trauma center.
Josh Weber [00:04:07]:
Some of the primary ways we really use our 340B savings for patient care across that patient journey is really focused on access and especially pharmacy access to some of these life saving medicines is critical. So twofold here or actually threefold, we're really trying to push a lot to home delivery. Patients really want access right to their doorstep and so they want that one click kind of option. Second is our home infusion strategy. So really launching an industry leading home infusion program with focus on expanding patient access where they are right in some of these rural areas. So a lot of ambulatory infusion suites, even a mobile RV really doubling our chair capacity. And then last but certainly not least, I'm really excited launching our 330,000 square foot central service center that combines supply chain, centralized, sterile, compound and repackage and operation and will be the future home of our specialty home delivery and central fill options. And that'll really help us expand service offerings to our communities.
David Glendinning [00:05:08]:
That all sounds wonderful. And I understand you're relatively new to St. Luke's so thank you for being a quick study on all of the great ways they serve patients there. So let's talk specialty pharmacy for a bit. That's certainly your area of expertise. Why is specialty pharmacy such an area of importance for 340B hospitals like St.
Josh Weber [00:05:28]:
Luke's so really you have to understand our patients are not just specialty patients or they're not just like home delivery or retail patients. A lot of patients are on specialty meds also might have retail needs too. So for us we really wanted to be the primary provider, if you will, from a pharmacy service level and specialty pharmacy services is critical to that. Oftentimes these patients have things like oncology, MS, dermatological conditions, a lot of things that really affect their quality of life and their health. Right. And so we really wanted to be that sole provider. We've also seen in the market a surge in specialty drugs. Currently it's about 55% of net 340B spend in a program that's over $100B annually.
Josh Weber [00:06:12]:
So it's really critical to invest into specialty pharmacy services. Primary drivers are still like the oncology, the autoimmune disorders or neurology, Ms. Patients. But we're really starting to see pickup in what we like to call specialty light. So dermatology, even diabetes. Right. And so how we approach that might be different because it's more high volume. So we can't do that same level of like high touch.
Josh Weber [00:06:37]:
But we still need to have some kind of patient management program to capture those patients too. Lastly, specialty pharmacy allows 340B hospitals to create high touch, high value care models that really differentiate us from commercial providers. We see that if you can keep your patients in your own health system, they just have superior outcomes, whether that be turnaround time, speed to therapy, clinical outcomes. It's just the whole gamut. Right. We really see patients have better experiences. Our providers really love it. And you know, at the heart of it, you know, 340B savings really allows us to kind of reinvest and to grow those programs even more.
Josh Weber [00:07:17]:
So the opportunity is just tremendous in the space.
David Glendinning [00:07:20]:
Yeah, some of the stats you mentioned about that surge in specialty drug use, you know, it's important to realize that when 340B started, there were hardly any specialty drugs. And now that is certainly not the case anymore. So what is the thinking, the general thinking behind embedding clinical pharmacists, specifically in that specialty space that you described?
Josh Weber [00:07:42]:
Yeah, we like to see our clinical pharmacists really as value multipliers. Our clinical pharmacists are really doing things like care coordination, meeting with patients, going over how to administer the medications, doing things like side effect mitigation or split fill programs to reduce waste. So if you're an oncology patient and you're your dose is changing rapidly over the first two weeks. Why would we send a 30 day script home when you're going to change it maybe three times in two weeks? And so our payer friends really love to see that because it reduces per member per month spend upwards of $1,000 to $1,200 per month. So that's just one example. We also see faster speed to therapy. So that's a critical kind of KPI if you are a marker of success. It really starts from that point of prescription entry into the health system to patient hazard in hand.
Josh Weber [00:08:32]:
So we like to target less than 48 hours. The industry kind of centers around 10 to 14 days. So that's a huge benefit. Better adherence. We have PDC scores historically above 90% and then less abandonment risk. So all those three things kind of really play into our value story. And when you integrate into our integrated delivery network, you can really track data, right? So data is the currency of today's specialty market, right? You gotta be able to get your claims data, your disposal, your outcomes data, and you have to be able to share that with external stakeholders, right? Because that's critical for their value stories and their mission so that our payers and our pharmaceutical partners, so pharmacists really identify gaps in therapy and make timely interventions to really ensure that patients optimally benefit from these high cost therapies.
David Glendinning [00:09:19]:
We're always interested in the 340B angle, of course, with any story we tell. So what is that angle here? Where does 3340B fit into this embedding approach for eligible hospitals that take that approach?
Josh Weber [00:09:34]:
So it's a critical piece of the ROI puzzle, right? So 340B savings is crucial. We like to look at three things. We like to look at patient volume, right? What is the drug spend? So 340b savings factors into that lever very much so. And then what is the payer mix, right? So all three of those determine like how we approach embed in resources into a clinic. If we improve adherence though and refill retention. So if you focus on those two outcomes, right, you have patients stay on therapy and you make sure it's refilled timely. The 340B savings actually like exponentially increases. And we really use that to invest into those things, like our ambulatory infusion strategy, right? How do we improve access in our communities? How do we grow our medication access? You know, that team alone, like really helps the gatekeeper, if you will, to make sure things are accessible and affordable for patients.
Josh Weber [00:10:27]:
And then we have better patient outcomes as the goal. But 340B really enables us to reinvest in that care. Internal specialty models tied to 340B can really insulate hospitals too from. Contract pharmacy restrictions are very hot topic. As you know, David, you know, contract pharmacy restrictions these days are really hard to kind of justify the financial headwinds that health system entities face. And so if you internalize and fill it at your own specialty pharmacy, that's the best way to mitigate risk. So that's been critical for us.
David Glendinning [00:10:59]:
You mentioned the term value multiplier before, which is a term I really like. How does that value multiplier appear in the wild to providers and patients at hospitals that adopt this strategy you've been describing?
Josh Weber [00:11:15]:
Yes, I like to think of the value multiplier more like tied back to kind of the triple aim of health care. Right. We want to dispense lower cost services, higher quality of care, but still have great patient and provider experience level. So when we embed clinical pharmacy services into specialty pharmacy, we know that care can often be fragmented when rely on an external specialty pharmacies. Right? We hear that from patients, we hear that from providers. We can see it with data, right? It takes, you know, sometimes upwards of 30 days to get med in hand. And so we really want to take that on as a health system and say we can do better, right? And we can divide devise infrastructure that really kind of maximizes our value and really helps our patients. So you know, take prior auth for example, doing that in 48 hours versus that 10 to 14 days from a patient level that means the world to them.
Josh Weber [00:12:07]:
You know, you have to imagine these patients, some of them are newly diagnosed cancer patients, newly diagnosed multiple sclerosis, going through a lot of different barriers and quality of life, you know, issues at that time. And how can we help be a patient advocate in that standpoint. So management programs really means getting the right med to the right patient at the right time. And so that's critical. So when we do this well getting back to that AAA and we see a lower cost of care, right, per member per month for payer friends. We also see better net promoter scores. So upwards of 96, 95% for both patients and providers. And the care delivery gets much better.
Josh Weber [00:12:47]:
So we track that differently with different outcomes. But you know, adherence scores go up and clinical outcomes improve and then even our patients patient reported outcomes, so things like quality of life or different ways that they measure things too also improve. So doing that well kind of multiplies throughout the patient journey.
David Glendinning [00:13:04]:
I know during your presentation here at the 340B Coalition Summer Conference you mentioned cell and gene therapies. So I suppose we can add CGT to this ever growing list of acronyms that we use in the 340B world. Why are these therapies such a big factor in this discussion?
Josh Weber [00:13:24]:
Just a little statistics here. Why we call cell and gene in the rare disease category, it's really, although not that rare, right. There's 450 million patients worldwide that have one of 7,000 rare diseases. And this is, I can't believe this number, but less than 7% have an FDA approved therapy. You know these cell and gene therapies are very novel, right. They can oftentimes halt disease progression, reverse it or stop it. These are patients that might be, you know, six months old, that their prognosis is unfortunately, you know, not being alive in two years. Right.
Josh Weber [00:13:59]:
And so from a patient perspective, a caregiver perspective, we as a health system really need to redesign care delivery models to expand access to some of these FDA approved medications. So the market is, it's growing. We have 2000 cell and gene therapy is currently in development with 500 in the pipeline. About 10 to 20 per month are being FDA approved. So we've really got to really kind of focus here and invest into this area. Most target those rare or ultra rare diseases that could cost upwards of 3 to 5 million dollars for a single dose. So, right, you have to do things differently. You have to have single case agreements with your payers, you have to have launch strategies with your pharmaceutical partners.
Josh Weber [00:14:39]:
340B pricing here, where available, can really help our hospitals absorb that high upfront cost and really expand access. So another great way like 340B savings is critical to our mission as an organization. It really underscores the need for pharmacist led tailored navigation for these complex patient journeys.
David Glendinning [00:14:58]:
Wow, three to five million dollars for a single drug, that's, you know, mind boggling. As you mentioned, it is saving lives of course, but I can see the need to have a plan here to be able to tread carefully. So what specifically can clinical pharmacists accomplish with those types of drugs in that space?
Josh Weber [00:15:17]:
Yeah, you can really kind of lead the efforts at your health system. Right. You can enable things like launch readiness. So really designing the workflows, the treatment plans inside your EHRs, really ensure timely navigation for providers, maintain compliance with things like REMs agreements and follow up on outcomes. As an example, payment in sickle cell disease, there's actually an outcomes based reimbursement model for this already where a lot of places and payers are saying, hey look, if we front this 3 million dollar, let's say on average gene therapy, what is the outcome we're going to get? What does that look like? And so a lot of times it's value based agreements. And so as an example, it might be less transfusions Right. Or decreased healthcare utilization rates. And so they want to see like an investment of that magnitude really pay off in clinical outcome improvement.
Josh Weber [00:16:11]:
And they're baked into contract language. So our pharmacists are critical, right, to doing this. Well, we meet with and especially pharmacy infrastructure that's already in place is a great basis point to start, right? Because we're already following with these patients. We can assess, hey, is this therapy the right fit for this patient at this time? And then from there we do their initial assessments, we do the follow up assessments. We can really like, you know, really kind of focus on making sure they optimize that therapy. It's not just that single infusion, that one time dose, it's the regiment that comes with it. It's toxicity monitoring, it's order in the labs, it's following with the patient adherence to steroids, for example. So all of those things come into mind.
Josh Weber [00:16:51]:
But you know, our clinical pharmacists are really can be kind of designing the info, the infrastructure and be the architects of that care delivery at an enterprise level.
David Glendinning [00:17:01]:
So Josh, you've made a very good pitch here for those architects as you describe them. So once hospitals are sold on this idea, how do they determine where to embed pharmacists?
Josh Weber [00:17:14]:
So it's really, you got to consider things like, like drug spend, right? Patient volume, payer mix, right? So is it Medicaid, Medicare, commercial, they all require kind of different service model and investment strategies. How we're going to integrate, right? Do we want to embed resources directly in clinic or hey, maybe we embed some resources, but we centralize other processes like benefits, investigations, then clinic proximity, right? Develop heat maps. Where, where are our patients? Are they in certain hospitals or in certain clinics? Does it make more sense to invest more resources in certain places? You know, take for example our infusion strategy that was driven by, you know, there's a three year old patient. This is a great story to share, right? Three years old, him and his mom would have to drive upwards of two hours one way to an infusion chair, spend three hours on site and then have to drive two hours back weekly for some injections. And you know, that's just not the care we want to provide. And so we've realized that and that that patient story really helped us. You know, that dictates kind of sometimes where you put resources in. So we really want to integrate pharmacists into innovative workflows.
Josh Weber [00:18:25]:
You know, things that come to mind are how we leverage our EHR to centralize benefits with things like msat or multi step order transmittal process and really kind of focus in on centralizing and improving access, speedily access to therapy, things like real time prescription benefits. And so if you do that, you drive down initial PAs, but you also guess what, you improve utilization management for our payers. And so when we talk to payers, that's part of our value prop deck. And then we operate a center of excellence model, right? So we contract especially in the cell and gene space for site activation from a center of excellence approach. But ultimately David, it comes to putting the patients and their caregivers at the center, right? You have to start there and build out from that point.
David Glendinning [00:19:09]:
When this strategy that you describe is successful for a 340B hospital, when it does everything you want it to, what does it look like for those involved?
Josh Weber [00:19:18]:
So from a patient perspective, they really see that they're going to be taken care of throughout their journey, Right. And so this is apparent in, in different ways they get their therapies faster, they might get it delivered right to their home, they might be able to just go down the street for their infusion if needed. Right. And so all of that improves their quality of life and improves their adherence to therapies and ultimately their outcomes. And it's reflective in their experience scores. Right? Again, our net promoter scores are above 95%. External pharmacies simply just can't touch that number. Right.
Josh Weber [00:19:49]:
And so that's critical. Providers see clinical pharmacists as really critical team members and extenders, if you will, who, when you do it well, providers can see more patients. But maybe we use things like predictive data analytics to really see these patients from a pharmacist level every month, whereas to see their specialists every six months. And that way we can really improve that adherence. We can help with side effect mitigation, we can decrease therapy, abandonment, et cetera. So ultimately, you know, this is one of those fewer areas in business where everybody can win, right? Patients do better on their meds, delivery costs go down, experience goes up, right? That's that triple aim that we keep talking about. And our places like St. Luke's and other health systems can really generate more of those 340 billion savings to reinvest into their communities.
Josh Weber [00:20:38]:
So for us at St. Luke's what does that look like? There's over a billion dollar in community benefit annually that we, we give out. Roughly about 500 million is for under reimbursed care. You know, 50 million of that is really tied to charity care. And then we in Pharmacy really use 340B savings through a program called 340B assist where we give a million dollars a month to cover co pays and make sure any patient on any med can afford their therapy and really one less barrier that they have to deal with these complex diseases. Reward data and patient stories from successful specialty pharmacy models really help protect 340B. Once we become that definition of what service excellence looks like, it's really impossible for external stakeholders to ignore and this is really a call to action. How do we partner better with payers and our pharmaceutical partners right in the 340B space to really keep the patient at the center.
Josh Weber [00:21:36]:
And so the way we do that is through things like 340B policy engagement and hopefully in action right to make sure like these patients and these programs are protected and really advocacy support. So really taking that to really define what it is our future wants to look like. So that's what I see as success in this space.
David Glendinning [00:21:54]:
Well, thank you for mentioning advocacy without my even having to prompt you to do it. You're making the rest of our comms team and certainly our gift, our team. Very happy to hear that. Josh. I very much enjoyed this chat. This is a fascinating topic to me and thank you so much for being here.
Josh Weber [00:22:11]:
Yeah, thank you very much David. Really appreciate the opportunity and thank you for the time.
David Glendinning [00:22:16]:
Our thanks again to Josh Weber for going back to back at the 340B Coalition conference to share the St. Luke's story on specialty pharmacy and the clinical pharmacist's role in that area. These conferences offer far more practical information about 340B operations and compliance topics than we can cover on the podcast. So if you have not yet signed up for the next winter conference occurring February 9th to 11th in San Diego. Please go now to 340bwinterconference.org to register and take advantage of early bird discounts. We look forward to seeing you all on the west coast early next year. We will be back in a few weeks with our next episode. In the meantime, as always, thanks for listening and be well.
Narration [00:23:06]:
Thanks for listening to 340B Insight. Subscribe and rate us on Apple Podcasts, Google Play, Spotify or wherever you listen to podcasts. For more information, visit our website at 340bpodcast.org. You can also follow us on Twitter @340bhealth and submit a question or idea to the show by emailing us at podcast@340bhealth.org.