Pharmacy Benefits Uncut

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With the vast majority of employers viewing high drug prices as one of the biggest threats to the affordability of their healthcare plans, they need every tool at their disposal to achieve value for their drug spend. But there’s one strategy that most of them are missing: an approach to health equity focussed on medications.

As an employer you achieve health equity when all your members have a fair opportunity to improve their health to the greatest extent possible. You achieve pharmacoequity, a key element of health equity, when all of your plan members have affordable access to high-quality medications that improve their health.

Although it may seem surprising, inequities in access to medications persist within employer-sponsored pharmacy benefits plans. Recent data have shown a considerable number of employees have experienced cost-related non-adherence to their medications, including skipping doses, reducing doses, and delaying filling prescriptions or simply not filling them to save money. Employees at greatest risk of these inequities include those who belong to racial and sexual minority groups as well as those in lower incomes groups.

If you, as an employer, however, are unaware of these inequities it’s unlikely you're addressing them. And this could cause financial toxicity for your plan members (the inability to afford medications) that leads to clinical toxicity (deterioration in their health conditions requiring additional, more costly care such as emergency department visits), ultimately costing you more in the long run.

The good news is that developing a pharmacoequity strategy represents a big opportunity for you to move towards value for your drug spend. In fact, it’s low-hanging fruit that many employers don’t even recognize.

Here are the three key components you need to include in your pharmacoequity strategy.

Component #1: Data on inequities in medication access

To meaningfully address inequities in medication access, you need to understand the types of disparities your plan members are experiencing and identify the members most at risk of these disparities. The only way to do this is to gather and analyze your plan members’ data.

One source of data is healthcare claims. Examining even a simple data point such as time intervals between prescription fill dates could help identify plan members who are potentially at risk of cost-related non-adherence to their medication regimens.

Other data points such as rates of emergency department (ED) visits could also identify plan members who are having ongoing difficulty paying for their medications. ED visits serve as a proxy measure of care accessibility for plan members and may reflect inequities in access to medications.

Another, perhaps more reliable source of data, is from plan members themselves. Employers who can gather data related to obstacles in accessing medications directly from individual plan members are best positioned to address these inequities.

Collecting this type of data will require developing customized survey and communication tools, as well as a highly engaged plan membership willing to participate in this effort. Employers who can pull off this strategy will be able to formulate personalized, “high-touch” solutions for specific groups of plan members or even individual members who are experiencing, or at risk of, inequities in medication access.

Component #2: Explicit equity considerations in all pharmacy benefits decisions

As you’re no doubt aware there are many different aspects to your pharmacy benefits plan including PBM contracts and drug formulary management. The decisions you make in these areas have equity implications for your plan members.

That’s why you need to implement processes to explicitly and systematically consider equity when addressing every part of your pharmacy benefits plan. Here are two examples.

​As I’ve written before, high PBM rebates perpetuate high list prices for drugs. Since out-of-pocket costs such as prescription co-payments are based on a drug’s list price, as the list price increases so does the member’s share of the cost. This phenomenon is likely to worsen already existing inequities in medication access and potentially create new ones. Explicitly considering the equity implications of pursuing a high-rebate strategy, ostensibly designed to lower drug costs, should lead you to consider alternate ways to ensure the financial sustainability of your pharmacy benefits plan.

Similarly, decisions related to which drugs to list on your formulary have equity implications. Many expensive new drugs whose effectiveness is uncertain are approved by the FDA, and including these drugs on your formulary will likely require premium increases for you and your employees, as well as increased plan member cost-sharing. These additional costs ultimately come from employees’ wages, thereby directly or indirectly affecting plan members’ ability to pay for their medications, a factor you should always consider when making formulary decisions.

Component #3: Clinical services to optimize medication use

Your plan members can have access to the best, most effective medications but their health isn’t going improve if they’re not using them properly. A key component to achieving pharmacoequity for your plan members is providing them with access to clinical pharmacy services so they have the support necessary to ensure success with their drug therapy. These services are especially critical for plan members who live in areas known as pharmacy deserts: low-income communities with limited access to pharmacies. Plan members living in these areas are more likely to face other barriers to accessing healthcare including lower education levels, belonging to racial or ethnic minority groups, difficulty speaking English, and ambulatory disabilities.

Employers who provide comprehensive medication management services either through on-site clinics, virtual clinics, or relationships with community pharmacies are best positioned to optimize their plan members medication use since CMM not only addresses health equity issues, but also improves chronic disease management, reduces overall healthcare costs and enhances plan member satisfaction with healthcare services.

A Pharmacoequity Checklist for Employers

All employers need a pharmacoequity strategy to give plan members access to high quality medications that improve their health and reduce healthcare costs over the long term.

Here’s how you can get started:

Gather information. Identify which of your plan members are experiencing or at risk of inequities in medication access. Implement a system to gather this type of data on an ongoing basis. Consider developing a plan member engagement strategy focused on equity.

View all decisions through an equity lens. Evaluate the equity implications of every aspect of your pharmacy benefits plans. Keep in mind that some strategies designed to decrease drug costs or improve access to new medicines may in fact have the opposite effect of exacerbating existing inequities.

Promote appropriate medication use. Make sure your plan members have access to clinical support services so they’re achieving the best possible health outcomes from their medications. This is particularly important for plan members who don’t have easy access to community pharmacies near their homes.

That’s all for today.

See you in two weeks,

Nina

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Pharmacy Benefits Uncut is produced by Healthcare Decision Making, a consultancy that helps small and medium sized employers optimize their pharmacy benefits plan. We offer a comprehensive range of services focused on three areas: PBM procurement, ongoing management of your pharmacy benefits plan, and self-policing and oversight of your pharmacy spend. To learn more about how Healthcare Decision Making can help you, email Nina Lathia at nina.lathia@healthcaredecisionmaking.com

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