Advancing patient access and practice stability through medically integrated dispensing: Insights from Dr. Norman Gaylis
By Featured article
Medically integrated dispensing (MID) – a care model whereby specialty medications are dispensed directly within a provider’s office or clinic rather than via an external pharmacy – is emerging as an impactful strategy for strengthening rheumatology practices at a time reimbursement pressures, biosimilar shifts, and payer requirements are reshaping the specialty. After decades of innovation in biologics and infusion therapy, many practices now face shrinking margins, rising administrating burdens, and difficulty sustaining high-quality, high-touch care. In the face of these challenges, MID can help providers improve patient care, increase treatment adherence, and reduce financial barriers to medications, while accessing a new revenue stream for their practices.
Dr. Norman Gaylis is one of the country’s leading rheumatologists. Based in Miami, he has been treating patients for over four decades. In addition to his clinical work, he is actively involved in ongoing clinical trials studying a variety of treatments for rheumatic diseases and serving as a principal investigator in new pharmaceutical products. Since implementing MID in his rheumatology practice five years ago, he has experienced a variety of benefits including an improved continuity of care, speed to therapy, and adherence for patients, as well as a new revenue stream for his practice. He credits MID with helping him maintain a thriving medical office in his community. In this Q&A, he explains why he launched MID, what it takes to build and staff an in-office dispensing program, and how MID can help rheumatology practices thrive in a rapidly changing environment.
Dr. Norman Gaylis is one of the country’s leading rheumatologists. Based in Miami, he has been treating patients for over four decades. In addition to his clinical work, he is actively involved in ongoing clinical trials studying a variety of treatments for rheumatic diseases and serving as a principal investigator in new pharmaceutical products. Since implementing MID in his rheumatology practice five years ago, he has experienced a variety of benefits including an improved continuity of care, speed to therapy, and adherence for patients, as well as a new revenue stream for his practice. He credits MID with helping him maintain a thriving medical office in his community. In this Q&A, he explains why he launched MID, what it takes to build and staff an in-office dispensing program, and how MID can help rheumatology practices thrive in a rapidly changing environment.
Q: What problem in rheumatology care is MID best suited to solve right now?
Dr. Gaylis: MID helps rheumatology practices create a sustainable revenue stream that supports continued access to advanced therapeutics. After 45 years in practice, including involvement in early research on the original biologics, I’ve watched reimbursement steadily decline across patient care, clinic visits, and especially infusion services. Over the last decade, margins on infusible products have shrunk, authorizations have become more burdensome, and the shift to biosimilars has changed the entire pricing structure. We reached a point where practicing high-end, cutting-edge rheumatology with the newest and most effective therapies was being jeopardized by affordability.
If I wanted to keep my practice open and continue providing the level of care my patients needed, something had to change. We were prescribing a large volume of injectables and oral therapies, yet receiving no compensation for the extensive staff time required to secure approvals. These medications were essential for our patients’ health but detrimental to the practice’s financial health. That’s what led us to explore in-house dispensing – capturing the prescriptions we were already generating and managing them ourselves.
Q: What does tighter coordination between the prescriber and dispensing team mean for the patient experience?
Dr. Gaylis: Our practice was already operating via a high-touch model for infusion care. Once we launched MID, it added another level of involvement. Patients might not speak directly with me but are in constant contact with my pharmacy and infusion staff to coordinate authorization and navigate insurance requirements to access the therapies they need. So many of my patients have become friends with my pharmacy and infusion staff because their consistent interaction is so critical.
We work within a very complex system. Oftentimes, we have pharmacy benefit managers tell us which therapies we must use and which medications need to fail before we can implement the ones we want. That constant dialogue creates intimacy and trust between staff and patients simply by virtue of getting them access to treatment.
Further, dispensing also improves adherence. With infusions, we know when a patient needs to come in and can call them if they miss an appointment. That level of oversight doesn’t happen when a specialty pharmacy serves as the intermediary. When a drug is shipped to the patient, we don’t have confirmation they actually received what they needed or that the shipper didn’t just leave it on the front porch to sit in the sun for hours rendering it useless. Because MID allows us to treat patients directly, we know they’ve received the right dose of the right medication when they’re supposed to. It’s a parallel benefit that’s essential to delivering consistent, reliable care.
Q: What staffing model makes MID sustainable in rheumatology?
Dr. Gaylis: I recommend starting with people who already understand the types of drugs you’re prescribing, the diseases you’re treating, and the problems you run into. When you bring in someone new, there’s a learning curve to reach the level of comfort and efficiency to run this type of program well. When we launched MID, we leveraged our existing team. For example, two of our medical assistants hadn’t previously worked with pharmacies, but they understood the therapies we were using and the foundations and copay processes. Our billing department also played a critical role in managing copays and out-of-pocket responsibilities.
As the program grew, we hired new staff members to support the existing team. The value of the program quickly offset the additional staff we hired, and over time, our MID program has progressively become more profitable and productive.
Q: Wht’s the ROI timeframe a rheumatology practice should expect after launching MID?
Dr. Gaylis: Practices should anticipate being cash flow negative for up to six months after launching an MID program. Once you identify the right patient population and understand which prescriptions will successfully adjudicate, growth and profitability will rapidly accelerate. Rheumatology patients are long-term patients, which helps create steady growth. Over four years, we’ve seen consistent increases in both prescription volume and profitability.
Q: What have you learned since launching MID in your rheumatology practice?
Dr. Gaylis: First, you need patience. There will be denials, step-therapy requirements, and moments when someone who has never seen your patient is telling you which medication to use based simply on cost. It’s very frustrating, but it’s all part of the process.
Second, there is a learning curve. We were early adopters of MID, so we had a lot to figure out – but now I’m teaching other rheumatology practices how to do it. In the beginning, success really depends on teamwork, problem-solving, and a willingness to continually refine workflows.
Third, payer mix is critical. Medicare and Medicare Advantage patients are the most reliable group because they don’t dictate which pharmacy you must use. For practices starting MID today, a Medicare-leaning population is the strongest foundation for success.
Q: What organizational prerequisites matter most?
Dr. Gaylis: You must have a “champion” within the practice. Every successful practice I’ve seen – whether it’s made up of two physicians or ten – has one or two people who are drivers. You need someone who has the knowledge, the desire, the energy, and ultimately the drive to make the program successful.
Q: Are there other revenue streams practices should consider alongside MID?
Dr. Gaylis: Clinical research is a major opportunity – it provides revenue, elevates the practice’s reputation, and gives patients access to new therapies. Rehab, physical therapy, osteoporosis services, and nutraceuticals can also be valuable additions, especially for aging populations or patients with mobility challenges.
Diagnostic services like X-rays and bone density testing remain important, and labs may be worth considering despite payer restrictions. Ultimately, the goal is to create a one-stop-shop for patients. They shouldn’t have to go to four different places for care. When everything is integrated under one roof, it improves quality, convenience, and the overall patient experience.
Looking ahead
For rheumatologists, MID doesn’t just add value – it can be the difference between maintaining patient access to advanced therapeutics and struggling to keep the doors open. As reimbursement pressures intensify and infusion margins continue to decline, MID is becoming essential to the success of rheumatology practices. With thoughtful planning, the right workflows, and a clear understanding of payer dynamics, rheumatology practices can utilize MID to deliver more coordinated, patient-centered care while building a sustainable model for the future.
Dr. Gaylis: MID helps rheumatology practices create a sustainable revenue stream that supports continued access to advanced therapeutics. After 45 years in practice, including involvement in early research on the original biologics, I’ve watched reimbursement steadily decline across patient care, clinic visits, and especially infusion services. Over the last decade, margins on infusible products have shrunk, authorizations have become more burdensome, and the shift to biosimilars has changed the entire pricing structure. We reached a point where practicing high-end, cutting-edge rheumatology with the newest and most effective therapies was being jeopardized by affordability.
If I wanted to keep my practice open and continue providing the level of care my patients needed, something had to change. We were prescribing a large volume of injectables and oral therapies, yet receiving no compensation for the extensive staff time required to secure approvals. These medications were essential for our patients’ health but detrimental to the practice’s financial health. That’s what led us to explore in-house dispensing – capturing the prescriptions we were already generating and managing them ourselves.
Q: What does tighter coordination between the prescriber and dispensing team mean for the patient experience?
Dr. Gaylis: Our practice was already operating via a high-touch model for infusion care. Once we launched MID, it added another level of involvement. Patients might not speak directly with me but are in constant contact with my pharmacy and infusion staff to coordinate authorization and navigate insurance requirements to access the therapies they need. So many of my patients have become friends with my pharmacy and infusion staff because their consistent interaction is so critical.
We work within a very complex system. Oftentimes, we have pharmacy benefit managers tell us which therapies we must use and which medications need to fail before we can implement the ones we want. That constant dialogue creates intimacy and trust between staff and patients simply by virtue of getting them access to treatment.
Further, dispensing also improves adherence. With infusions, we know when a patient needs to come in and can call them if they miss an appointment. That level of oversight doesn’t happen when a specialty pharmacy serves as the intermediary. When a drug is shipped to the patient, we don’t have confirmation they actually received what they needed or that the shipper didn’t just leave it on the front porch to sit in the sun for hours rendering it useless. Because MID allows us to treat patients directly, we know they’ve received the right dose of the right medication when they’re supposed to. It’s a parallel benefit that’s essential to delivering consistent, reliable care.
Q: What staffing model makes MID sustainable in rheumatology?
Dr. Gaylis: I recommend starting with people who already understand the types of drugs you’re prescribing, the diseases you’re treating, and the problems you run into. When you bring in someone new, there’s a learning curve to reach the level of comfort and efficiency to run this type of program well. When we launched MID, we leveraged our existing team. For example, two of our medical assistants hadn’t previously worked with pharmacies, but they understood the therapies we were using and the foundations and copay processes. Our billing department also played a critical role in managing copays and out-of-pocket responsibilities.
As the program grew, we hired new staff members to support the existing team. The value of the program quickly offset the additional staff we hired, and over time, our MID program has progressively become more profitable and productive.
Q: Wht’s the ROI timeframe a rheumatology practice should expect after launching MID?
Dr. Gaylis: Practices should anticipate being cash flow negative for up to six months after launching an MID program. Once you identify the right patient population and understand which prescriptions will successfully adjudicate, growth and profitability will rapidly accelerate. Rheumatology patients are long-term patients, which helps create steady growth. Over four years, we’ve seen consistent increases in both prescription volume and profitability.
Q: What have you learned since launching MID in your rheumatology practice?
Dr. Gaylis: First, you need patience. There will be denials, step-therapy requirements, and moments when someone who has never seen your patient is telling you which medication to use based simply on cost. It’s very frustrating, but it’s all part of the process.
Second, there is a learning curve. We were early adopters of MID, so we had a lot to figure out – but now I’m teaching other rheumatology practices how to do it. In the beginning, success really depends on teamwork, problem-solving, and a willingness to continually refine workflows.
Third, payer mix is critical. Medicare and Medicare Advantage patients are the most reliable group because they don’t dictate which pharmacy you must use. For practices starting MID today, a Medicare-leaning population is the strongest foundation for success.
Q: What organizational prerequisites matter most?
Dr. Gaylis: You must have a “champion” within the practice. Every successful practice I’ve seen – whether it’s made up of two physicians or ten – has one or two people who are drivers. You need someone who has the knowledge, the desire, the energy, and ultimately the drive to make the program successful.
Q: Are there other revenue streams practices should consider alongside MID?
Dr. Gaylis: Clinical research is a major opportunity – it provides revenue, elevates the practice’s reputation, and gives patients access to new therapies. Rehab, physical therapy, osteoporosis services, and nutraceuticals can also be valuable additions, especially for aging populations or patients with mobility challenges.
Diagnostic services like X-rays and bone density testing remain important, and labs may be worth considering despite payer restrictions. Ultimately, the goal is to create a one-stop-shop for patients. They shouldn’t have to go to four different places for care. When everything is integrated under one roof, it improves quality, convenience, and the overall patient experience.
Looking ahead
For rheumatologists, MID doesn’t just add value – it can be the difference between maintaining patient access to advanced therapeutics and struggling to keep the doors open. As reimbursement pressures intensify and infusion margins continue to decline, MID is becoming essential to the success of rheumatology practices. With thoughtful planning, the right workflows, and a clear understanding of payer dynamics, rheumatology practices can utilize MID to deliver more coordinated, patient-centered care while building a sustainable model for the future.
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