By Sandra Morris, Senior Advisor, GTMRx Institute
Formerly Senior Manager, US Benefits, Procter & Gamble
March 10, 2021
“We’re trying to change the status quo and transform pharmacy benefits.”—Cheryl Larson, CEO, Midwest Business Group on Health (MBGH)
Why employers should care about optimizing medication use
Several times a year, health care benefits managers and health plan administrators (medical carriers and PBMs) meet to review interactions that occurred between the administrators and health plan members or their providers: How many calls were answered; how quickly they were answered; what discount was received from billed charges (inflated enough by providers so the after-discount payments closely resemble what they would have charged without the discount); how many prior authorizations were performed; and on and on and on. We leave these meetings still wondering what we can do so our companies stop paying for illness versus health. We search for measures to confirm that the outcomes needed to improve employee health and sustain company profitability are within reach.
We return to our sparsely staffed departments to see CEO messages asking for our plan to reduce our expenses/budgets and hear “do more with less” echo down the hallways. We go home and can’t sleep as our minds struggle to create plan design strategies that produce measurable savings through positive care outcomes. We fear the impact of the next catastrophic medical case or release of a blockbuster “me too” medication with little or no clinical—or employer—value.
By now, you are probably thinking that I either have extrasensory perception or I’ve had experience managing employee health care benefits. I spent 25 years designing and implementing U.S. employee benefits for a Fortune 50 company and many sleepless nights worrying over health care strategy. Now I spend my sleepless nights as an employer consultant—an insane but dearly loved way to live.
I wish I could say this toolkit provides all the solutions you need for sound sleep. If that were true, you would have a new reason to worry—job security! Hardly anyone wants to walk in our shoes, but they are not shy about asking how much savings we are going to produce in a health care market with an inflation rate the size of the universe. We simply smile and respond with our rote explanations of the difference between cost savings and cost avoidance. And then we keep searching for solutions.
The GTMRx Institute has released an employer toolkit to provide the kind of knowledge and actions steps needed to:
- Understand why the current system of trial-and-error medication use must change for us to eliminate the health plan assets waste it creates. Elimination of plan assets waste is not optional. As our health plan’s fiduciaries, we have a legal responsibility to do so.
- Understand how comprehensive medication management (CMM) is being used today to effectively transform and optimize medication use while achieving measurable, positive treatment outcomes that save lives and money (CMM 10-step process).
- Grasp the value equation for employer advocacy and leadership of system transformation through CMM.
- Recognize why employers should be key leaders of change and the actions that will establish them as market leaders and champions of transformation to avoid medication overuse, underuse and misuse.
- Take action to become leaders of change. Our ineffective and often harmful system must transform to one that facilitates optimal medication use and delivers desired clinical outcomes for all Americans as quickly and cost effectively as possible.
Integrating CMM as a corporate health strategy
Employers manage the health benefits for 49% of this country’s total population.1 Because employers sign the checks, they have much to gain from optimizing the medications involved in 80% of all medical treatments.2 Research published in March 2018 highlights an eye-popping $528 billion was spent in just one year on unnecessary medical resources needed to resolve problems attributed to non-optimized medications ($528B Opportunity).3
The problem is not solely the inability to keep people on medications. It’s also a failure to optimize medication use. This requires going upstream in the medication use process and first ensuring every medication is appropriate, effective, safe, and that the patient is willing and able to take it as prescribed.
Employers as health plan sponsors pay for a product—the medication—without a process in place to ensure it’s used to the greatest advantage. Savvy business leaders would not invest in software that fails to integrate and maximize other data tools. Yet employers pay for the consequences of medication misadventures to the cost of hundreds of billions of dollars a year attributed to physician fees, ER visits, hospitalizations and long-term care resulting from medication-induced new medical problems and treatment failures—more than they paid for the medications to begin with!
Value-based health care delivery has been the benefits management watchword for more than a decade. Employers are at the forefront of the movement, incentivizing primary care to deliver whole-person, team-based care in a medical home framework. But somehow what has slipped by is the urgent need—and opportunity—to manage the entire medication use process. Granted, care delivery remains fragmented, preventing us from capturing a full picture of the quality, waste and tragic consequences, especially for high-risk patients who see multiple providers who prescribe multiple medications.
It’s time to change that. Implementing CMM as a core benefits strategy lowers costs and contributes to employee well-being. When employees are healthy, productive and at work, everyone benefits.
- Kaiser Family Foundation 2019 Employer Health Benefits Survey. https://www.kff.org/report-section/ehbs-2019-section-1-cost-of-health-insurance/
- McInnis, Terry, et al., editors. The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. 2nd ed., Patient-Centered Primary Care Collaborative. PCPCC Medication Management Task Force collaborative document
- Watanabe J, et al. Cost of Prescription Drug–Related Morbidity and Mortality. Annals of Pharmacotherapy, March 26, 2018. Accessed 3 April 2018. http://journals.sagepub.com/eprint/ic2iH2maTdI5zfN5iUay/full.