As the health care industry is experiencing a shift towards value based care and technology advancements, prescription drugs will play a progressively vital role in managing patient care and overall healthcare costs. Keenan Pharmacy Services has identified some important trends that plan sponsors should take a closer look at to help better manage compliance and pharmacy costs in the coming year.
Data Integration and Technology
A key driver in successfully managing patient care is the ability to integrate medical and pharmacy data to drive clinical decisions, ensure adherence, identify gaps in care and improve patient and provider communication. Increasingly a number of health organizations and Pharmacy Benefit Managers (PBMs) have announced partnerships with technology companies to improve prescribing decisions and determine what conditions are responsive to medication or clinical management programs. These various types of integrated solutions can generate clinical improvements and cost containment based on a patient’s documented behavior. One example of this type of actionable clinical outcome is integrating a diabetic patient’s pharmacy data with their HbA1c lab tests to identify gaps in care or deficiencies in adherence protocols. This is valuable information for patient education and outreach by their healthcare provider.
Specialty Drug Management
With specialty drugs expected to account for nearly 50% of total drug spend within the next 3 to 5 years, proper management of these drugs is critical. There is opportunity to control spend and improve outcomes by both expanding the data analytics and changing the way specialty drugs are prescribed and approved. The number of specialty drugs on the market continues to grow, and at the same time, the coverage of these drugs has moved from medical to pharmacy, with the prior authorization and approval process now managed under the PBM. Most PBMs focus on cost containment with negotiating aggressive discounts and manufacturer rebates for a lower net cost to the plan sponsor.
To ensure an unbiased, independent review, the approval of these drugs can be moved to an independent third party, similar to medical case management. Medical case management has existed for decades to oversee hospitalization and large case events for self-funded employers, which helps to ensure the entity profiting from care delivery is not also making medical necessity decisions. By decoupling the PBM dispensing and rebate profits from the clinical prior authorization review, it provides an unbiased, independent, clinical management review for these high cost medications. A recent case study for one of our clients identified a $38,000 savings to the plan sponsor when the initially prescribed high cost specialty medication was successfully changed by the provider to a lower cost, more effective alternative after a comprehensive review of the medical and pharmacy data.
With these improved data management capabilities and more robust clinical management programs, we can expect to see even further opportunities to improve the quality and value in pharmacy.
About Lisa Krajewski
Lisa Krajewski has over 20 years experience in the healthcare industry, with expertise in product development, account management and the administration of pharmacy, 340B and clinical programs. At Keenan, Lisa provides client oversight and assists organizations throughout the country with operational assessments, financial and compliance matters including contract and revenue analysis, vendor evaluation, account and project management support.