The American Journal of Pharmacy Benefits

Drivers of Change in Pharmacy Benefit Management | Page 1

Published Online: June 20, 2014
Jan Berger, MD, MJ; Louis L. Brunetti, MD; Robert DaSilva, RPh; Shareh O. Ghani, MD; Kevin Hirsch, MD; Mumtaz Ibrahim, MD; Michael Kobernick, MD, MS, FAAEM, FAAFP; Robin J. Richardson, RPh; Scott Schnuckle; Justin Weiss, PharmD; and Richard Bankowitz, MD, MBA, FACP
The Affordable Care Act (ACA) and increasing regulation has had a significant impact on healthcare delivery. Changes continue to unfold across all segments of the healthcare continuum. In many areas, regulation and guidance have been silent or vague on pharmacy care. The purpose of this study is to identify the drivers of change in pharmacy benefit management in the next 18 to 36 months and articulate strategies for plan sponsors to adapt effectively to these drivers and continue to provide economically sustainable drug benefit programs.


A qualitative research study was conducted in January 2013 with pharmacy leaders who hold executive-level positions in US managed care organizations (MCOs) and other healthcare alliances. The 11 respondents provided written answers to research questions about:

  • Impact of reform to date on medical services, pharmacy, and health and wellness services;

  • Impact of medical loss ratio (MLR) requirements on pharmacy;

  • Opportunities that accountable care organizations (ACOs) can offer to improve the practice of managed care pharmacy;

  • Impact of health insurance exchanges (HIExs) on pharmacy benefit management; and

  • Action steps for drug benefit plan sponsors to ensure that they can provide drug benefit programs in 2014 and beyond.

The written responses to the research questions were synthesized, reflecting differences of opinion, uncertainty of future events, and unknown outcomes associated with changes in the marketplace. Respondents reviewed the research findings together via conference calls in the second phase of the study to arrive at a consensus on the study findings.


This section discusses the detailed research findings. Verbatim comments of respondents are italicized.

Role of Pharmacy Evolves, Increases in Importance

The role of pharmacy will become more prominent in care delivery as healthcare reform unfolds.

“Pharmacy will be forced out of its silo and into the care team.”

Pharmacists will be tapped for their cognitive expertise and become integral members of patient care teams. With greater accountability for patient outcomes, providers will increasingly rely on pharmacy for patient-specific medication adherence information (particularly for chronic and complex conditions), identifying and managing gaps in care, and providing medication reconciliation at care transitions.

Successful ACO models demand more integration—of data, incentives, care plans, and healthcare services. Integration of medical and pharmacy data will be essential.

“The time has come for the physician community to stand up and be counted. We have always asked for more control of how we practice medicine. The ACO concept offers a unique opportunity for us to ensure that the care we deliver is high quality with better outcomes and at reduced costs, while enhancing the patient experience. This means that physicians can no longer be agnostic to costs whether they are in the medical arena or pharmaceutical arena. The physician needs to leverage both clinical and technological tools to enhance the clinical enterprise. The days of serving in isolation are over. We need to be interlinked together and use the infrastructure that the ACO offers in offering care management to our patients.”

Healthcare reform presents opportunities to elevate the role of managed care pharmacy by showcasing its best practices and bringing them to the medical side of healthcare.

“The discipline and effectiveness of drug pricing strategies on the pharmacy benefit side of the business will continue to migrate to the undisciplined management strategies under medical benefits. Pricing, preferred drug strategies, rebates, and utilization management are much more effective on the pharmacy benefit. I anticipate that health plans will begin to apply the pharmacy benefit strategies on those drugs managed on the medical benefit.”


“I believe that pharmacy already has a quality reputation. As most attention is not currently focused on pharmacy, this is pharmacy’s opportunity to be proactive. As limits to patient cost sharing are implemented, pharmacy’s focus on helping programs/plans work within medical loss ratio requirement and within global budgets will be significant.”

Other emerging challenges include:

  • Growth in specialty drug expenditures triggered by higher prices, more therapeutic options, and growing utilization;

  • Member “churn” in and out of Medicaid and subsidized insurance plans; and

  • Quality being secondary to immediate demands of health reform implementation.

Drivers of Change in Pharmacy Benefit Management

In addition to the evolving role of the pharmacist, there are many other issues that will drive change in pharmacy benefit management as illustrated in the Figure. Drivers are listed in descending order of importance in each category.

Emerging Models of Care Integrate Pharmacy, Medical Care

The promise of fully integrated healthcare reform should translate to improved patient care with economic benefits for all stakeholders. The respondents commented on the growing impact of MLR requirements, ACOs, and HIExs. They believe that there will be continued pressure to reduce unnecessary administrative costs that could adversely affect MLR requirements, although pharmacy is not perceived as a huge percentage of overall cost. More costs of drug utilization management programs could be attributed to MLR if the quality management aspects of these types programs had stronger measurement and reporting to articulate their clinical value.

The role of pharmacy and pharmacists will become more prominent going forward. Physicians are, to varying degrees, beginning to appreciate that role. Clinicians working within integrated health systems already utilize pharmacy expertise to optimal or near-optimal capacity. The challenge remains with physicians practicing outside of truly integrated delivery systems, not only in regard to pharmacy but to overall care coordination. Further, there is a range of viewpoints about whether ACOs are an end point or simply an important step to transitioning to a future, yet-to-be-defined improved model.

Much of the current regulatory guidance on ACA implementation does not address pharmacy issues for ACOs in HIExs in much detail. Furthermore, separation of risk among payers and providers within government-prescribed ACO models has the potential to create perverse incentives: pharmacy risk resides with payers, whereas medical risk is shared with, or shifted to, providers. The belief is that commercial ACO models will follow the same approach for now, but eventually they will move toward integrating pharmacy and medical in terms of financial risk. Some plan sponsors (integrated health systems and MCOs) are already able to successfully integrate these benefits/risks, but other organizations where pharmacy and medical have historically been siloed find it difficult. For these organizations, the “proof of concept”—a unified effort is better than the sum of individual parts—may help speed integration efforts and bring policy makers’ attention to the issue.

The measures of success for the “proof of concept” ideally should follow the triple aim framework addressing patient experience (quality and satisfaction), population health, and cost. Attribution of success to individual interventions or components of care (pharmacy, medication adherence, etc) is not seen as essential, as it might detract from the overall goal.

Implications for Strengthening Sustainability of Drug Benefit Programs

Aggressive management of the drug benefit and of the pharmacy network are seen as critical to the ability of the MCOs’ to provide affordable access to drugs.

“Aggressive formulary management. Rebate optimization for branded drugs. Continued push toward generics. Step therapies broadly implemented. Increasing cost sharing with members as appropriate. Mandatory participation of members in specialty drug programs.”

Efficient execution of value-added programs such as medication adherence programs should result in overall cost reduction, but this depends heavily on integrating pharmacy and medical claims and data capture systems. These integrated systems are prerequisites to new types of contracts that will include outcome guarantees and mechanisms to attribute value to different stakeholders for specific activities and/or outcomes.

“Plan sponsors should be expanding their information technology resources or information partners to measure more than pharmacy cost, generic prescribing, etc… their clients will expect measurement of quality which includes more than just pharmacy claims. Integration of pharmacy, lab and encounter data will become common offerings of PBMs (pharmacy benefit managers).”

One respondent suggests that standardization and simplification of benefits and administration will be necessary, echoing similar observations about the impact of exchanges on pharmacy benefits.

PDF is available on the last page.

Issue: May/June 2014
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