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By: Chris Syverson
Chief Executive Officer
Nevada Business Group on Health/Nevada Health Partners

Self-insured* employers: Drive improved patient experience and ROI via CMM

August 11, 2021

Chris Syverson is the chief executive officer for the Nevada Business Group on Health/Nevada Health Partners. She leads a group of public and private employers in direct contracting for health care services as well as employee and community health. She also serves on the board for the National Alliance of HealthCare Purchasing Coalitions, as vice chair of the Nevada Community Board for CoMagine Health and on the Nevada Advisory Council on the State Program for Wellness and the Prevention of Chronic Disease (CWCD).

Self-insured employers are in the driver’s seat for health benefit plan design. And in many ways, the GTMRx Institute’s Employer Toolkit provides a roadmap for them to achieve the dual goals they try to balance every day: patient experience and return on investment.

Both benefit managers and senior leadership struggle with how to offer the best service at the best price and also achieve the best outcomes. Unfortunately, patient experience is often the element lost in the mix. We have tried so hard to maximize the cost savings* that we don’t always think about how many times a patient has to call their doctor or go to their pharmacy to get a different medication, or how many co-pays and deductibles they have to pay to get to the right medication for them.

The patient experience deserves more attention than it gets.

I work primarily with small-to-medium-sized, self-insured employers that have control over plan design. I believe writing CMM into their benefit agreements will achieve this patient experience and ROI balance. Why?

First, we know it reduces trial-and-error prescribing and achieves better care. Most plans today are structured to begin with a standard medication for a diagnosis to try first and “see if it works.” Especially when you consider the high cost of treatments like chemotherapy, this is managing cost at the expense of the patient. Personalizing care by using tools like genetic testing will reduce the time to get to the right medication regimen, lower out-of-pocket costs and get employees back to health and productivity faster. There is a wealth of evidence that CMM improves patient care and patient experience.

Second, there’s proven ROI. We know there is a lot of waste in the current system. There is ample evidence that CMM reduces waste on several fronts—by curtailing unnecessary hospitalizations, ER and physician visits and use of the wrong medications. Evidence shows that the financial ROI for CMM programs average around 3:1 to 5:1 and can be as high as 12:1, resulting in a reduction in the direct mean medical cost of between $1,200 and $1,872 per patient per year. When we focus in on what medication regimen works for that specific individual based on their age, other medications they use and health factors, how much could we save?

It is essential to make CMM adoption as easy as possible for health benefit administrators. Fortunately for self-insured employers, the GTMRx Institute Employer Toolkit provides much of what is needed to incorporate CMM into health benefit design.

  1. In Employers as health plan sponsors: How to contract for CMM services (click “Contracting for CMM” in the Employer Toolkit Resource Center), there is a wealth of guidance for preparing the scope of services for a CMM request for proposal and for clearly describing the CMM capabilities and services sought.
  2. The Employer Toolkit overview document defines CMM and provides the 10 steps required to achieve it, so you can easily explain CMM as a clearly differentiated discipline within medication therapy management. This document also offers:
    1. A brief description of who benefits most from CMM;
    2. Points to guide initial discussions with health plan carriers and PBMs; and
    3. Immediate ways to exercise your contract authority, such as waiving step-therapy requirements when CMM is utilized.
  3. Use cases point the way. Seeing how other organizations have incorporated CMM into their benefit design and learning from their trailblazing work is phenomenally helpful. Being able to look at what an employer has done to implement CMM and read about their trials and successes makes it easier to make the case to senior managers, too. If others have done this, you can, too.

The more I dive into these resources, the more I’m convinced that it just makes good sense to adopt CMM. Yes, the tools help you make the business case, but in my experience, everyone knows a story about someone who has had an experience where identifying the right medication made all the difference.  We’ve become accustomed to the current system, but there is a better way. This real-world, common-sense argument resonates not only with employees, but also with the C-suite.

Benefits managers should boldly make the case. We owe it to the nearly half of U.S. workers who rely on employer-based health benefits to get the medications right.

*Updated 8.13.2021

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