Pharmacy Benefits Uncut

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Although you may not be aware, suboptimal medication use – incorrect dosages, non-adherence, using the wrong drug, experiencing adverse effects - costs the American economy a staggering amount of money: over $500 billion a year, representing more than 15% of total healthcare expenditures.

The good news is you as an employer have the power to fix this problem.

The solution is comprehensive medication management (CMM). CMM involves individually assessing each medication a patient is taking and evaluating whether it’s appropriate for the patient based on their condition, their comorbidities, and other relevant factors. The goal of CMM is to develop an individualized care plan for patients with specific, defined health outcomes that can be measured and adjusted as required through regular follow-up.

Not Providing CMM is Costing You Money

Although there will be some up-front costs to establishing and operating a CMM service, the long-term savings make this strategy a no-brainer for every employer.

Studies have conclusively shown the financial benefits of CMM. A study of 290 patients in Texas who received CMM estimated potential cost savings of over $1 million largely resulting from resolving drug therapy problems that prevented high-cost hospital admissions and ER visits. Another study of 2150 patients in a large Medicaid plan who received CMM found that total cost of care for these patients was reduced by almost 20% per month, again driven by reduced hospital admissions and ER visits. The authors of this study reported a greater than 12-times return on investment when costs of implementing and maintaining the CMM program were included.

Imagine being able to save this amount of money on your healthcare spend!?

What You Need to Implement CMM

As an employer, you need two things to provide CMM: 1) participation from your plan members, and 2) access to clinical pharmacy services.

Needless to say, CMM requires buy-in from your plan members, since they need to be full partners in the process of optimizing their medications. Ideally you’ll engage with your plan members to understand their specific needs related to medication management, whether it be modifications to their medication regimens, a trusted provider to turn to whenever they have questions, or perhaps even issues related to obtaining and paying for their medications.

Also be aware that certain plan members may be more likely to benefit from CMM, including those not achieving the desired outcomes from their drug therapy, those experiencing medication side effects, those having difficulty adhering to their medication regimens, those who need preventive therapies, those suffering from chronic diseases, and those who’ve been frequently admitted to hospital. Steering these members toward CMM services will likely yield outsize benefits both for them and for your healthcare plan.

CMM also requires access to clinical pharmacists who are specifically tasked with providing this service. Ideally these pharmacists would be integrated into plan members’ primary care teams to ensure collaborative, seamless, patient-centered medication management. Of note, greater than 90% of primary care providers (physicians, nurse practitioners) who have pharmacists as part of their care teams are extremely satisfied with the services they provide. They also feel pharmacists help decrease their workload and enable them to focus on aspects of their work they find more fulfilling. Of course, it may not always be possible to integrate CMM into primary care, and in these situations, it could be provided through on-site clinics, local community pharmacies, or even virtually.

The Power of CMM

In addition to substantial cost savings to your overall healthcare plan, CMM has many other benefits. The first and most important is an improvement in plan member health. CMM has been shown to improve blood sugar control in diabetics, reduce blood pressure in patients with cardiovascular disease, prevent drug interactions, and reduce post-discharge hospital readmissions in high-risk patients.

CMM also improves plan member satisfaction and trust with the healthcare system, increases access to primary care services, and helps to address health inequities. A quintuple win!

The Bottom Line

Drug therapies are the most common medical treatment, representing 80% of all healthcare interventions. As such, they have tremendous potential to both help patients if used optimally, as well as harm them if used sub-optimally. Medication-related problems are consuming a growing share of healthcare expenditures, but if you prioritize optimizing your plan members’ medication use, you’ll go a long way to achieving sustainable overall healthcare spend. It may take a lot of effort to implement a CMM service for your members, but it’s a smart investment that will pay huge dividends in the long run.

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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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