Embracing pharmacy care management for high-value care delivery
The recognition of the important role of pharmacists in clinical care has been trending higher in recent years, and for good reason. Pharmacists have the right knowledge and are positioned to positively impact care in today’s quality-driven healthcare climate.
Industry groups are increasingly recognizing the role of effective medication management in achieving clinical benefits and improved costs. Two important trends that are affecting patient outcomes and cost are medication adherence and the rising cost of generic and brand name drugs.
To combat the $290 billion in annual expenses associated with non-adherence in the United States, many payers and pharmacies are turning to pharmacy care management. Industry statistics specifically reveal that only 50 to 70 of every 100 prescriptions are filled by patients and only 25 to 30 are properly taken, creating notable risk in terms of optimizing patient outcomes and realizing a return on investment for high-cost medications. As the industry works toward providing value-based care (rather than volume-based), these types of behaviors can adversely affect value-based care goals.
For example, a patient with hepatitis C may leave a pharmacy with a prescription that costs $30,000. If the patient does not properly take the medication, the value proposition of drug cost versus clinical benefit is minimal. It can be difficult for providers and pharmacists to improve quality of care if patients aren’t taking their prescriptions correctly. Treatment goals are best met when patients adhere to the treatment that is prescribed.
Pharmacy care management enables patients to receive medication consultation immediately upon authorization to allow prescribed therapies to be understood before the first dose is consumed. Not only is the pharmacist able to immediately evaluate whether a drug conforms to the patient’s medical needs, they are also able to educate and follow the patient through each step of the care timeline.
The reality for today’s payers and pharmacies is that authorization systems are generally not designed for the fee-for-value model. Often, there is only a snapshot of patient demographics provided when high-cost medications are authorized. But, caregivers need access to the full picture in order to develop an effective care plan. Pharmacy care management provides an added layer of protection to optimize medications and allow patients to realize the full benefit of their therapies.
Consider the Medicaid system as an example. Like many payers, case managers struggle with the resources to effectively manage chronic disease and a safety net program. Medicaid is required to accommodate all medication needs, generally regardless of cost.
When a pharmacy care manager is linked to a Medicaid case manager to specifically focus on tactics for medication success, the potential impact on quality outcomes can be significant because pharmaceutical clinical expertise is added to the equation. Plus, pharmacy care management services that leverage the latest technology can manage patients in real-time by identifying those who are not following through with prescriptions and refills.
One organization that serves a large Medicaid population leveraged pharmacy care management services in 2013 to focus on education, adherence and proper use of medications among 583 of its 320,000 members. With the right technology infrastructure in place to support direct contact between pharmacy care managers, prescribers and members in real time, the organization achieved $1.76 million in direct cost avoidance savings after one year.
Pharmacists are now a critical part of the healthcare team. Pharmacies that capitalize on the unique knowledge base and expertise that these professionals bring to care delivery can have greater success in moving the needle on outcomes and performance in the value-based healthcare landscape.
Laureen Biczak is the medical director of Goold Health Systems, a Change Healthcare (formerly Emdeon) Company.