Health System Specialty Pharmacy Model Shows Promise for Diabetes Outcomes and Total Cost of Care

Key Takeaways

• Health system specialty pharmacy may play a broader role in value-based care by supporting chronic disease management, not just medication access.
• High-risk diabetes patients may benefit from more intensive pharmacist-led support, particularly when standard specialty pharmacy services are expanded into care coaching.
• The model described by UMass Memorial Health and Shields Health Solutions combined medication management, care coordination, social needs support, and behavioral health referral within a single workflow.
• Reported outcomes included lower total medical expense, fewer emergency department visits, fewer hospitalizations, and improved A1C levels among patients in the program.
• Medication adherence and affordability were central parts of the intervention, with speakers highlighting refill support, financial assistance, and regimen simplification. The speakers positioned health system specialty pharmacy as a potential population health tool, especially for patients with chronic conditions that drive utilization in value-based care arrangements.

At Asembia 2026, speakers from UMass Memorial Health and Shields Health Solutions described how a health system specialty pharmacy model is being used as a care management platform to support value-based care for patients with diabetes in a session titled "Health System Specialty Pharmacy as a Care Management Platform to Support Value-Based Care."

The session featured Samir Malkani, Clinical Chief, Division of Diabetes, Endocrinology and Metabolism, UMass Memorial Health; Bill McElnea, Vice President of Population Health, Shields Health Solutions; and Hinal Sharma, Diabetes Care Coach, Shields Health Solutions.

Using UMass Memorial Health’s diabetes clinic as the primary example, the speakers outlined how embedding specialty pharmacy support into chronic disease management can help address medication adherence, social determinants of health, behavioral health needs, and care coordination for high-risk patients. They also presented results suggesting the model may improve clinical outcomes, reduce utilization, and lower total medical expense in value-based care populations.

Specialty Pharmacy’s Role Is Expanding Beyond Traditional Functions

McElnea opened the session by describing how specialty pharmacy continues to evolve, with pharmacists and pharmacy teams taking on broader responsibilities in patient support. He said UMass Memorial Health and Shields Health Solutions have spent several years exploring how far the specialty pharmacist skill set can extend in caring for chronically ill patients.

That work led to the development of a care coach program designed to provide more comprehensive support than traditional pharmacy services alone. According to the speakers, the goal was not only to improve patient outcomes, but also to examine whether that level of support could reduce healthcare expenditures and support value-based care performance.

UMass Diabetes Clinic Focused on Patients With Persistent Poor Control

Malkani described UMass Memorial Health as the largest healthcare system in central Massachusetts, with four hospitals and a specialty diabetes clinic that sees about 10 000 patients annually.

He said the health system’s specialty pharmacy program began supporting the diabetes clinic in 2019. Initially, the pharmacy team functioned in a more traditional liaison role, helping patients access medications and navigate approvals. Over time, however, the clinic identified a subset of patients with persistently elevated hemoglobin A1C levels despite receiving specialty endocrinology care.

According to Malkani, about 15% of the clinic’s diabetes patients had an A1C above 9% chronically. The care coach program was created to provide additional support for those highest-risk patients.

Care Coaches Address Adherence, Lifestyle, Social Needs, and Behavioral Health

The speakers described the care coach model as more closely aligned with comprehensive care management than with conventional pharmacy support.

Patients referred into the program were those with prolonged poor glycemic control despite ongoing medical care. Care coaches had access to the patient’s medical record, treatment plan, glucose data, and pharmacy fill history. That visibility allowed them to identify adherence issues, understand patient barriers, and coordinate closely with the broader care team.

Malkani said care coaches worked with patients on a range of needs, including:

• Medication adherence and refill patterns
• Financial barriers and enrollment in patient assistance or free care programs
• Medication titration between visits in coordination with providers
• Diabetes education and lifestyle counseling
• Social determinants of health, including housing, transportation, and job instability
• Behavioral health concerns, including depression and other mental health needs
• Patient motivation and long-term engagement

He also noted that because care coaches built trust with patients, many patients ultimately transferred prescriptions to the specialty pharmacy, which created an additional business benefit that could help offset program costs.

Patient Cases Highlighted Both Clinical and Social Impact

Sharma presented two patient case examples to illustrate how the model functioned in practice.

The first case involved a 39-year-old woman with type 1 diabetes who entered the program with an A1C of 9.4. Sharma described a history of misinformation about diabetes management, mistrust of the healthcare system, and significant mental health challenges. Through gradual coaching, goal setting, remote monitoring, and referral to behavioral health support, the patient’s A1C improved to 7.7. Sharma said the patient also reported better confidence, stronger engagement with care, and improved quality of life.

The second case involved a 51-year-old woman with type 2 diabetes who entered the program with an A1C of 9.3 after years of struggling with disease management. Sharma said the patient had difficulty maintaining a routine and consistently taking medications. Over time, the care coach focused on adherence, regimen simplification, and social needs support. When the patient later faced a housing crisis, the team used embedded social needs screening and connected her to a care coordinator through her insurance plan. According to Sharma, the patient ultimately achieved A1C levels below 6.5 and was able to graduate from the program.

Together, the case studies were used to illustrate how a specialty pharmacy-based care management model may affect both medical and nonmedical drivers of health.

Program Results Suggest Lower Cost and Utilization

McElnea then reviewed the program’s reported results, with a particular focus on UMass Memorial Health’s Medicare accountable care organization population.

He said UMass has participated in the Medicare Shared Savings Program since 2015 and that its ACO now manages about 43 000 lives. Among Medicare ACO patients in the care coach program, he said total medical expense one year after participation was more than $2600 lower than in a closely matched control cohort drawn from the same clinics.

The speakers also reported utilization reductions across the broader care coach population. For every 100 patients in the program, they said there were:

• 15 fewer emergency department visits
• 22 fewer hospitalizations
• 3.7 fewer hospital days

On the clinical side, average A1C reportedly fell by about 1.5 points.

McElnea also highlighted pharmacy-related metrics, stating that among patients who filled through the UMass specialty pharmacy program, adherence remained above 90% and average copays remained below $10.

Implications for Value-Based Care and Population Health

A central message of the session was that health system specialty pharmacy may be able to contribute more directly to population health and value-based care strategy than is often assumed.

McElnea said that for health systems able to perform chronic disease management at scale, specialty pharmacy may function not just as a dispensing and access resource, but also as a tool to help improve outcomes and manage cost in populations tied to value-based contracts.

He suggested that many of the same capabilities developed through specialty pharmacy—particularly around complex patient support, high-touch engagement, and coordination across multiple needs—can be applied to chronic conditions such as diabetes, chronic obstructive pulmonary disease, and heart failure.

For payer audiences, the presentation pointed to a model that could be relevant in several settings, including Medicare accountable care organizations, Medicare Advantage, and self-funded employer plans.

Reference

Malkani S, McElnea B, Sharma H. Health system specialty pharmacy as a care management platform to support value-based care. Asembia. 2026. Las Vegas, NV.