Pharmacosynchrony: Road Map to Transformation in Pharmacy Benefit Management
Published Online: April 15, 2014
David Calabrese, RPh, MHP; Neil B. Minkoff, MD; and Kristine Rawlings, PharmD
Across the country today, our healthcare leaders are moving forward in an attempt to reengineer our healthcare system and drive much-needed improvements in access, coordination, quality, and cost-effectiveness of care delivered to our US citizens. As this reengineering unfolds, the pharmacy benefit management industry is also presented with an ideal opportunity to transform itself as a critical contributor in helping to drive these national objectives. In an effort to capture the untapped value that pharmacy benefit managers (PBMs) bring to the table and help guide this transformation, we have developed and introduce here the concept of “pharmacosynchrony.” Pharmacosynchrony represents the application of innovative clinical, analytic, and technologic pharmacy solutions to drive improved care coordination and a higher-quality, more patient-centric model of care.
It appears to have become universally accepted that the healthcare system in the United States is highly dysfunctional. Care remains highly fragmented and increasingly more complex, with a lack of coordination being the norm.1 Population management has still not been widely adopted except as needed for a few commonly reported Healthcare Effectiveness Data and Information Set (HEDIS) measures. Meaningful use legislation has led to a significant increase in implementation of electronic health records (EHRs), but the lack of health information exchanges limits flow of information.2,3 The Institute of Medicine’s seminal work, “Crossing the Quality Chasm,” states that all of the above leads to higher cost of care.4
As a response, payers and providers are embracing newer healthcare delivery models as promising means of improving the healthcare system. Adoption of new models such as the patient centered medical home (PCMH) and the accountable care organization (ACO) is being accelerated by healthcare reform. PCMH has become defined as a full-service primary care practice model that supports integrated care, with emphasis on quality improvement, care coordination, and population management.5 ACOs are integrated units that coordinate primary and secondary care across inpatient and outpatient domains and are dedicated to population management for chronic disease. They are built to enhance cost effi ciency through reduced waste and to drive improved outcomes through tighter care coordination.6 Early evidence is encouraging enhanced adoption of these models across market sectors, demonstrating that both PCMHs and ACOs can produce better-quality outcomes with lower costs.7-10
Currently, fewer than 5500 practice sites are accredited by the National Committee for Quality Assurance (NCQA) as PCMHs.11 The Centers for Medicare & Medicaid Services (CMS) initially identified only 32 organizations nationally with the experience and maturity to be included in its Pioneer ACO program to test provider organizations’ ability to bear high levels of shared savings and risk.12
While this transformation is encouraging, most of the provider community lacks appropriate infrastructure to support the underlying functions that turn a traditional practice into a PCMH or ACO.13 Most physicians do not practice on a site that can support these functions, and contracting entities such as independent physician associations have not fi lled this void. Consolidation in the provider market may be changing this dynamic, but current estimates are that the majority of healthcare is provided in offices of 1 or 2 physicians.14
Currently, PBMs perform many functions for the safe and effective use of medications, including managing the preferred drug list or formulary, processing prescription claims and payment for insurance, controlling prescription costs, and utilizing programs to limit inappropriate medication use. The PBM’s existing programs, claims, and communications platforms put them in the best position to support the strategic objectives set forth by health plans, provider groups, and health systems as they transition toward more sophisticated delivery models. Expansion of PBM services to increase value for patients and providers has included reducing barriers to initiating medications for chronic illnesses, improving adherence for chronic medications, and encouraging cost-effective medication use by suggesting generic medications and formulary compliance.15 PBMs need to advance their role in the delivery of healthcare during this time of dramatic change in the US healthcare system. Change is necessary to improve medication use and avoid adverse events, expand connectivity to real-time prescription use, enhance reporting to evaluate patient outcomes, and leverage the clinical resources of PBMs to improve medication use by harnessing the data and making them accessible to healthcare providers.
OPPORTUNITY TO DRIVE ENHANCED VALUE
Development of the PCMH and ACO infrastructure is a key opportunity for PBMs. Approximately 75% of healthcare costs in the United States today are driven by chronic illnesses including diabetes, cardiovascular disease, stroke, and cancer.16 Pharmaceuticals represent the most powerful tools in effectively managing these conditions, decreasing their progression, and improving overall patient functionality and quality of life. While new models of care are adopted, more comprehensive and advanced means of managing prescription drug therapy remain widely overlooked and undervalued as components of these models.
Our concept of pharmacosynchrony represents a compilation of tools and services by which the PBM industry can foster improved levels of partnership with managed care clients and the provider community to support improved care coordination in a more comprehensive, largely virtual manner. Improved care coordination is the cornerstone of healthcare reform and population-based health management. Key to this partnership is the PBM’s ability to leverage advanced information technology (IT) platforms while marrying such platforms with comprehensive clinical resources and expertise.17 The healthcare system of the future will find much less value in the traditional business model of the PBM serving primarily as the processor of prescription drug claims and providing basic clinical programming and analytics to manage prescription utilization only. In the world of the PCMH and ACO, the PBM will be expected to develop new levels of clinical programming, information exchange, and analytics to provide a much more robust and holistic level of support and service. The PBM must develop new means of connectivity with the provider and patient community to facilitate improved education and engagement in evidence-based standards of care.
Sophisticated data warehousing and analytics capabilities enable the PBM to perform the activities which assist health plan clients and providers with care coordination. Foremost, the PBM can employ well-validated risk adjustment methodology to claims data to assist providers in better pinpointing patients at higher risk of negative clinical outcomes. This will enable providers to more effectively target patients in need of closer follow-up and support a more judicious allocation of resources for clinical intervention. Effectively analyzed claims data will uncover patterns of prescriber and patient behavior, representing opportunities for education and intervention. A PBM’s ability to integrate and effectively analyze both medical and pharmacy claims activity in a near-real-time fashion enhances these aforementioned activities, while also assisting with monitoring timely improvements in important quality metrics such as pharmacy-based HEDIS performance measures.18
The current PBM model includes electronic communication with pharmacies, plans, and employer customers. To fill the void in the new delivery systems, the PBM must improve connectivity with the provider and patient communities via new vehicles such as the Web, mobile technology, and EHRs.19 Each will improve timely access to key data and information, such as patient-specific clinical alerts, permitting more proactive intervention. Improved connectivity and coordination of care can also help to prevent negative clinical complications and their associated higher expenditures. Lastly, continuous development and refinement of key quality-based performance metrics and reporting can assist in monitoring and benchmarking provider care and support new methods of quality-based payment reform.
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