Back in February, Managed Care Contributing Editor Joseph Burns wrote an article about Express Scripts (ESI) and their attempt to branch out behind its traditional Pharmacy Benefit Manager role and foray into managing overall health for a select group of companies. This appears to be a response to ever increasing pressure for transparent PBM contacts, and the idea has merit.
The companies trying this approach with Express Scripts are trying to remove some of the financial incentives that have traditionally been hidden in PBM contracts by negotiating a more transparent contract. They have, however, taken it a step further, looking to manage not only drug spend, but also to decrease overall health spend.
Express Scripts has spent the last year working with these companies trying to improve outcomes in disease states like diabetes and asthma, as well as some more specific areas desired by the employers. This is a significant change to how they have traditionally done business. This, of course, required that they make some changes.
Under the contract, Express Scripts hired population health managers to do daily monitoring of employees to identify gaps in care such as screenings or tests that are recommended for patients based on their age and gender. It also has hired academic detailers to educate prescribing physicians about the evidence of the clinical effectiveness of the most appropriate medications for each patient
Snezana Mahon, Express Scripts vice president of clinical programs
The project appears includes more traditional financial performance guarantees designed to decrease per-member-per-month drug dispensing in addition the new features included in a per-member-per-month administrative fee to implement the clinical program. This is an at-risk model. If the PBM fails to meet the metrics for either program, the company forfeits some or all of the additional fees. If they succeed, the are rewarded with a bonus.
The inclusion of clinical programs targeting things like Hemoglobin A1c levels for diabetic patients, and blood pressure for hypertensive patients is a good start. The savings potential on drug spend continues to diminish. Pharmacies are being paid rock-bottom for the drug product and the PBMs, while they unquestionably mark this up, have precious little room to further reduce drug spend. The potential savings on the medical spend is both a much larger, and a more productive target.
What is being attempted, however, is not a new or novel concept. These types of programs are have been, and are currently being implemented by community-based pharmacists around the country. Engaging community-based pharmacists who, not only have therapeutic relationships with patients (pharmacist-patient relationship), but also a collaborative working relationships with physicians and other providers, has positively affected patient care and health outcomes. It is through these relationships, and a team approach, that patients become engaged participants in their own health care leading to improved health and overall reduction in health care spend.
Additionally, community-based pharmacists are accessible to patients and can assess them for social determinants of health (SDoH) issues that may be affecting their access to medications. If an SDoH issue is identified, community-based pharmacists are integrated within their communities and can connect patients to the appropriate community-based organization (CBO) or social services department.
Utilizing pharmacists out in the community to manage and optimize drug therapy has been shown to significantly decrease overall health spend measured per-member-per-month. Using pharmacists in call-centers, as a PBM would do, may help move the needle some, but the real force in healthcare is in the trenches: with the pharmacists and pharmacies that already have a relationship with the patient.
Community-based pharmacists are better potential partners to accomplish the type of savings in health spend mentioned in the article. Local and national high-performing networks of pharmacies already exist around the country. These networks have already proven that they can move the needle to save on health spend. These networks have significant advantages over a PBM administered program because they use highly trained, local pharmacists who already have relationships with the patients and local providers. Pharmacists that are able to work personally, face-to-face with the patient.
This project mentioned in the article is exciting. It means that pharmacy’s attempt to transform the profession is working. We need to continue to push forward. We have an opportunity to remove pharmacy from the grips of the PBM industry if we can continue this movement. It is time to Flip the Pharmacy (FtP). Flip your pharmacy and Make every encounter count with your patients!
