A FOCUS ON VALUE-BASED CARE INITIATIVES

Based in Utica, New York, Mohawk Valley Health System (MVHS) serves approximately 600,000 people across Oneida, Herkimer, and Madison counties. The system has more than 30 medical offices and specialty clinics throughout the region and also includes Wynn Hospital, located in downtown Utica. The full-service, 373-bed facility and Level III trauma center opened in 2023 to replace two older area hospitals. It offers patients a range of medical and surgical specialties and has dedicated floors for critical care, intermediate care, and women’s health.

“For a medium-sized community hospital with no real ties to any large systems, Wynn Hospital provides a pretty impressive suite of services,” says Dr. Gary Zimmer, MD, FACEP, chief medical officer for MVHS and practicing emergency physician. The new hospital, he explains, is part of the health system’s overarching goal to expand its portfolio of valuebased care initiatives aimed at lowering costs while delivering better patient outcomes and higher-quality services to the surrounding communities.

CHALLENGE: CLOSING THE GAP IN PHARMACY SERVICES

As MVHS began its value-based journey, they realized being able to have specialty medications readily available to patients was a real gap, says Zimmer. “We had a lot of limitations and concerns about our ability to provide medical treatment to patients who needed it.”

Christopher Houle, PharmD, BCPS, BCGP, CDCES, director of pharmacy for MVHS, agrees. “Originally, we had a small employee-only pharmacy that only served our insured staff,” he says. This left providers and patients on their own to get access to treatment — which can be complex when dealing with specialty medications. “These therapies are often expensive, even with insurance coverage. They just aren’t always accessible to patients.” Adherence to protocols can also be an issue, adding even more of an administrative burden on providers to follow up with patients to ensure they take medications correctly.

“That’s when we started asking ourselves — how do we get medications to patients who need them with the least friction? How do we ensure we give them every opportunity to comply with medication regimens?” Zimmer says. The answer was clear. They needed to add specialty pharmacy services to their initiatives. The next question was: should they do it on their own or find an external partner?

THE SOLUTION: AN ONSITE SPECIALTY PHARMACY MODEL

For MVHS, building a specialty pharmacy centered on improving patient outcomes. “We felt bringing an expert on board would help us get the program up and running faster,” Houle explains. After exploring several options, MVHS ultimately chose CPS Solutions, LLC (CPS), one of the country’s largest pharmacy and hospital solution providers. According to Zimmer, what they liked best about CPS’ offering was their local care model. “The promise of real at-the-elbow support and having CPS pharmacy staff in our offices — not just remote support — was key for us. It’s just a much more personalized approach.”

Nicolina Castilla, PharmD, who was born and raised in Utica and now works for CPS as MVHS’ director of onsite operations, general manager, describes how the program works. “The CPS pharmacy team supports both physicians and patients from MVHS’ 30 medical groups and Wynn Hospital. We help patients access specialty prescriptions in a timely way,” Castilla says. “That includes getting prior authorizations and financial assistance for patients in need, so medications are available immediately.”

THE RESULT: HIGHER-QUALITY CARE, EASIER ACCESS, AND BETTER OUTCOMES

When prior authorization is required, the CPS team will start the process immediately so patients can receive their prescriptions as soon as possible. On average, the CPS team has achieved a 98% approval rate for submitted prior authorizations. “If the cost of the medication isn’t covered or the co-pay is too high, we’re going to hit the ground running for patients to fix it,” says Castilla. She and her team do whatever they can to help patients overcome financial barriers. As a result, they have secured over $6 million in financial assistance for their patients. According to Houle, taking the administrative burden of prior authorizations and financial assistance away from providers gives frontline clinical staff more time for quality patient visits.

Another way the CPS’ team is freeing up providers’ time is by helping patients better manage their care. They follow up with patients regularly to talk to them about how they are feeling, if they have missed any doses, and if they are having side effects. “This ongoing communication not only helps improve adherence rates but also reduces the number of sick calls coming into the office. We’ve found that many patient concerns are medication-related, which we’re now addressing before they even think to call the doctor,” explains Castilla. Monitoring adherence and helping patients make a plan to comply with medication protocols also reduces longer-term hospitalization and readmissions.

“It’s the concierge level of service that CPS delivers that makes the quality so good,” Houle believes. Patients seem to agree. MVHS achieved a remarkable Net Promoter Score (NPS) of 100 — earning them a spot as a finalist in the annual Managed Markets Insights & Technology (MMIT) specialty pharmacy patient choice awards for the second consecutive year.

THE SUCCESS: CONSISTENT GROWTH ON THE PATH TO A VALUE-BASED CARE MODEL

“In just three years, we’ve gone from a small employee-only pharmacy to a full-blown specialty pharmacy with a front-facing retail end right in downtown Utica so that we’re able to serve every member of the community,” Houle says.

The specialty pharmacy also earned its Accreditation Commission for Health Care (ACHC) and Utilization Review Accreditation (URAC) accreditations in the same time frame. “We found that dual accreditation opened doors to new payor and limited distribution networks for us,” says Castilla. “And that just means more access for our patients.”

“Achieving that expanded network access requires certain specialized knowledge and expertise,” adds Houle. “I never had that before working with CPS.” As a result, MVHS continues to serve more patients while demonstrating that they’ve achieved great clinical results. “The high-quality care and expanded access is a self fulfilling process — it’s a huge win for us and our patients.”

“I think the results we’ve achieved are the easiest way of describing our success — which is based on our choice of partner,” says Zimmer. By leveraging CPS’ expertise and fully customizable solution, “if we’d tried to achieve that on our own, I think it would have probably been a five- to eight-year journey.” Plus, he adds that based on the quick turnaround time — getting medications for patients, addressing payor issues, and providing financial assistance in a timely manner — the specialty pharmacy can now expand its reach. “With the success of the program, we are in a position to start conversations with other private practice specialists in the communities we support and bring our services to their patients to continue building on our value-based care initiatives.”