Drivers of Change in Pharmacy Benefit Management | Page 3

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
Healthcare stakeholders must remain vigilant about managing costs with all of the tools in the arsenal. The role of pharmacy is evolving and increasing in importance. There is an emerging market imperative to integrate pharmacy and medical services to optimize not only patient outcomes but the economic return on investment.

A wave of macroeconomic variables is flooding the market, dramatically impacting pharmacy benefit management. Waning employer commitment to providing health benefits may trigger not only higher overall healthcare costs but adverse selection in group and individual exchanges. Familiar managed care techniques to counter thes forces and their impact on pharmacy include:

  • Narrow pharmacy networks

  • Integrated care programs targeted to chronic diseases

  • Medication therapy management

  • Trend management tools for specialty pharmacy drugs

  • Measurable end points for clinical programs to monitor success

  • Innovative pay-for-performance models to reimburse pharmacists for cognitive services

Next Steps for Drug Benefit Plan Sponsors

The sponsors of drug benefit programs in all segments of healthcare must continue to look to the future. Critical action steps include:

  • Remaining nimble as healthcare reform unfolds

  • Continuing to plan to ensure your organization is equipped to respond to market dynamics

  • Monitoring emerging trends in healthcare, population management and outcomes measurement

  • Engaging members today to be prepared for greater member responsibility in the future

  • Gaining greater understanding of how to use health data so there is better comprehension of the populations for whom they manage care and/ or sponsor benefit programs

  • Developing the ability to integrate data from a variety of sources across the entire care continuum to facilitate a more fully functional integrated healthcare system

Take-Away Points

  • Impact of healthcare reform is evident in regulation, clinical services, and economics of pharmacy benefit management.

  • Pharmacy and medical care must become more integrated to create economically sustainable drug benefit management programs for the future.

  • Managed care techniques, including narrow pharmacy networks, integrated care programs, medication therapy management, cost trend management of specialty pharmacy drugs, and pay-for-performance models will help mitigate the potential adverse impacts of healthcare reform.
Author Affiliations: Premier Healthcare Alliance, Washington, DC (RB); Silverlink Communications, Burlington, MA (JB); Blue Cross Blue Shield Advantage, Phoenix, AZ (RD); Magellan Health Services, Phoenix, AZ (SOG); Scripps Health, San Diego, CA (KH); SummaCare Health Plan, Inc, Akron, OH (MI); Ascension Health, Detroit, MI (MK); ODS Health Plans, Portland, OR (RR); HealthPartners, Minneapolis-St Paul, MN (SS); Superior Health Plan, Austin, TX (JW); Intellus Consulting, San Diego, CA (LLB).

Source of Funding: This study was sponsored by MedImpact Healthcare Systems, Inc.

Author Disclosures: With the exception of Dr Bankowitz, Mr Schnuckle, and the corresponding author employed by MedImpact, each author received an honorarium from MedImpact for the time invested in research. The authors reviewed and approved manuscript.

Authorship Information: Concept and design (LLB, SOG, MK, SS); acquisition of data (SOG, LLB); analysis and interpretation of data (LLB, MK, JW); drafting of the manuscript (LLB, RD, MI, RJR, JW); critical revision of the manuscript for important intellectual content (JB, LLB, RD, KH, MI, MK, SS, JW, RB); provision of study materials or patients (LLB, KH); obtaining funding (LLB); administrative, technical, or logistic support (LLB); supervision (LLB).

Address correspondence to: Dana H. Felthouse, MBA, Vice President of Business Development, MedImpact Healthcare Systems, Inc, 10181 Scripps Gateway Ct, San Diego, CA 92128. E-mail: dana.felthouse@ medimpact.com.
Issue: May/June 2014
More on AJMC.COM