3 ways PBMs can take a more holistic view of member health

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Pharmacists have comprehensive training in healthcare, yet they are an underutilized resource. They have the potential to support a holistic, data-based view of a member’s health that eliminates errors and waste due to inappropriate prescription utilization. The U.S. healthcare system is wasting an estimated $750 billion per year, which is roughly 30% of current U.S. healthcare costs, according to the Institute of Medicine.

Here are three ways the pharmacy benefit manager can provide a complete view of each member’s care to enhance safety, reduce waste and control costs:

First, for members with more complicated medical scenarios — including those using specialty medications — PBMs should increase the value of their pharmacists by expanding clinical consultations to deliver effective coordination of care.

Five percent of people account for more than 60% of total medication spending. By providing these few members with complex diagnoses direct access to a pharmacist familiar with their case, PBMs can create a more productive dialog with them, improving quality of care. When the pharmacist has all available data elements, including medical diagnosis codes, they can review contraindications to medications, as well as preexisting conditions.

For example, some medications are not recommended for patients retaining water, as it may lead to heart failure. Moreover, pharmacists should also work with members and prescribers to modify dosing when medications are intolerable, thus reducing side effects. This consultative approach results in increased compliance and enhanced outcomes.

Maximizing these educational opportunities has the ability to impact member outcomes as well as help to reduce waste and increase savings.

Second, at the point of sale, pharmacists should be able to treat the member from a holistic view that takes into account more comprehensive data.

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Newer, more advanced technologies are able to identify waste and inappropriate or dangerous care at the point of sale. Medical data integration delivers the intelligence to determine any gaps in care. When gaps are identified, prescriber outreach can be conducted to address the issues. This empowers the pharmacist to change the current healthcare dynamic by preventing problems before a prescription is dispensed, thereby controlling negative outcomes while curbing escalating costs.

Third, PBMs should understand how individual members metabolize medications and define which medication will be most effective to improve members’ experience with the healthcare delivery system.

Another way to control utilization is the application of pharmacogenetic testing data, which details how a member’s ability to metabolize a medication impacts its effectiveness. Pharmacogenetic test data enables the PBM to work with the prescriber and modify prescriptions according to a member’s metabolism. This information transforms the expensive and exhausting trial and error approach associated with starting new therapeutic treatments by ensuring the right medication is prescribed the first time. Proactive and holistic care coordination with all data elements at the point of sale reduces waste, improves outcomes and delivers savings.

With just a few additional steps, we can save the healthcare system millions, while improving member health outcomes. This trumps all financial savings and it is how PBMs can make a lasting impact now and in the future.

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