Katherine H. Capps
Executive Director
GTMRx Institute
Part 3 of a three-part series for employers to improve outcomes and lower costs by getting the medications right.
August 14, 2019
Employers, use your contract authority with health plans and PBMs to save lives and drug spend
In parts 1 and 2 of this series, I described the game-changing $528 billion opportunity employers and public payers have to decrease waste as they seek to manage prescription medication costs and improve health outcomes.
If you are like many of the employers I talk with from both the public and private sector, you’re probably thinking, “that’s great, but today, I’m seeing specialty drug costs increasing and my overall drug spend increasing. And I’m trying to work in a system that’s full of middlemen, inflated costs and misaligned incentives that are working against me having any real impact.”
Employer payers play a critical role in transforming the delivery system to one that is patient-centric. In the age of precision medicine, “patient-centric” isn’t just insider buzz talk. We are quickly approaching a time where implementation of a systematic approach to medication use can optimize outcomes. In many circumstances, companion and complimentary diagnostics allow us to more accurately target medication therapy IF we leverage the care team expertise and ensure that they have access to point-of-care information.
There are additional tools available today to manage drug costs, quality and appropriateness. The GTMRx Institute urges employers to use your contract authority with health plans and PBMs to insist on programs that will ensure appropriate use of medications and gene therapies.
Getting value for the drug benefit spend starts with asking the right questions of your vendors and insisting on drug management strategies that drive appropriate use.
Start by asking your health plans and PBMs:
- For employees with chronic conditions, are you willing to move beyond adherence programs to the delivery of services that systematically monitor, evaluate and quickly intervene during and between physician visits to assure clinical goals for each therapy are being met and medications are appropriate and effective?
- Have you identified and do you contract for services offered by clinical pharmacists in collaborative practice with physicians delivering either disease state or comprehensive medication management (CMM) services in ambulatory care settings?
- Are you willing to design programs that will assure better use of medications through appropriate use of advanced diagnostics (pharmacogenomics, biologic therapeutic drug monitoring, other companion/complementary diagnostics)?
- Do you provide programs that proactively take action to review employees’ medications to ensure appropriate use, to avoid errors and adverse reactions to medications?
- Do you offer programs to help employees understand the when, how and why of their own medication use and how do you help them address any physical, mental/emotional or financial limitations to use?
Getting value for the drug benefit also starts with moving from a benefit design strategy using traditional formulary management to one that seeks to answer “is this the right medication for this person?” When payers leverage their contracting power, health plans and PBMs listen. And if they don’t listen, new partners offering new solutions are quickly entering the market.
There’s ample evidence that getting the medications right saves lives and saves money. More than 10 years of experience shows these strategies work.
The $528 billion dollar opportunity to get the medications right is not a pipe dream. It is absolutely attainable.
With employers, physicians, pharmacists, health IT innovators, drug and diagnostics companies, consumer groups, payers and health systems aligned to save lives and save money through comprehensive medication management, the GTMRx Institute is working to advance this systematic approach to medication use, focused on team-based care.
Join us. We need to do what it takes to answer that one, simple question: “Is this the right medicine for this person?”
