How a PBM Uses Patient Engagement to Improve Care Outcomes, Cost

August 05, 2019 - As the pharmacy benefit management landscape consolidates around a few monolithic players, it’s become increasingly difficult for independent challengers to carve out space for themselves in a dominantly payer-owned field. Even one of the largest independent pharmacy benefit managers (PBMs) in the United States found they could not compete on cost.

Luckily, the company does things a little differently: It’s quietly renounced traditional price-slashing models and built a unique business strategy around better patient care, in pursuit of a vision for lower healthcare costs and greater transparency across the medical and pharmacy benefits and across all episodes of care.

At the heart of their vision is a unique program launched in 2017 with five best-in-class specialty pharmacies, chosen because they offer patient-support services that improve logistics, promote access and adherence, and reduce costly healthcare episodes.

And it works. These partnerships have upheld the PBM’s belief that more empowered, knowledgeable, and cared-for patients have better outcomes and use the healthcare system more efficiently.

This is how the PBM carved out a true niche as the partner who cares about patients and lowers healthcare costs universally.

The PBM needed a trusted specialty pharmacy partnership that enabled them to help push through claims when needed and respond to events with agility and foresight, knowing that the specialty pharmacy was making the right decisions for patients and that these decisions would save money, not waste money.

Based on specialty pharmacy reports over the past two years, the PBM has found that the specialty pharmacy’s oncology patients have fewer hospital admissions, fewer side effects, and better adherence to their treatment plans. These patients have shown better outcomes and a lower overall cost for payers. The specialty pharmacy achieves these results through a boutique array of administrative and clinical proficiencies.

On the administrative side, the specialty pharmacy shoulders the burden of patient affordability, which often falls to PBMs: investigating benefits, researching grant opportunities, facilitating prior-authorization approval, and educating the patient on their appeal options if prior authorization is denied. This financial support, crucial to helping patients adhere to costly treatment plans, also frees up payers by eliminating back-and-forth with providers during enrollment and coverage determination.

Once patients gets on therapy, their journey through the healthcare system is just beginning, and more mountains beyond the financial issues loom between them and a return to good health: symptoms, side effects, logistics, dosage, swallowing pills, managing home infusions, entrusting their health to caregivers, making difficult decisions, and grappling with emotional tolls.

To navigate these challenges, patients may need expert clinical advice at any hour of any day. The specialty pharmacy also performs that role from the moment of enrollment.

From industry-leading time-to-first-fill to seamless shipping and refill management, the specialty pharmacy ensures there’s no logistical reason the patient should miss a dose. Pharmacy technicians perform monthly pill counts to check for compliance, over-compliance, and dose modifications, and they confirm refills and shipping the third week of every month’s treatment.

Dedicated specialty-pharmacy teams build relationships with each patient and help them navigate hurdles — ones that often lead to costly healthcare episodes and poor patient experiences.

Even before prescriptions are filled, patients receive a call from their pharmacist, who confirms their first dose and explains what to expect. This simple patient education can eliminate confusion and accidental nonadherence or over-adherence.

The specialty pharmacy’s nurses check in regularly to monitor patients’ tolerance to therapy, score the risk of nonadherence based on distress levels, and offer coaching and strategies for mitigating side effects, when many oncology practices don’t have the bandwidth to do so. They also alert the oncologists to any red flags: nonadherence, unsanctioned changes in the treatment plan, or side effects.

Sometimes the benefit is as simple as addressing emotional barriers and helping patients stay positive and hopeful throughout their journey.

This continuing care helps prevent unnecessary drop-offs due to misunderstandings or a sense of hopelessness, and it eliminates unnecessary ER visits and heads off costly adverse events — meaning investment in these services pays for itself when the true costs of care are considered.

The investment is customizable. In this case, the PBM’s chosen specialty pharmacy optimizes care through rigorous data collection and analysis and has re-engineered patient assessments to optimize data-capture for their daily reports, which detail the outcomes of every patient touchpoint and reasons for any ensuing decisions.

This data-driven approach has proven invaluable for the PBM, whose involvement in every dispense their specialty pharmacy makes has positioned them at the forefront of a huge paradigm shift, with a universal instead of per-unit insight into healthcare costs and an ability to prove to payers the causal relationship between true, compassionate patient-support services and more efficient use of the healthcare system. This PBM may be one of the first to grasp the nature of that relationship. They won’t be the last.

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About McKesson: With 25 years of proven clinical expertise in oncology and an emphasis on patient care, Biologics by McKesson was the natural choice to provide specialty pharmacy services for this PBM. Biologics patient-support services help patients stay adherent, mitigate the impact of adverse events, prevent avoidable drop-offs, and lower hospital admissions, resulting in better patient outcomes and lower overall costs for payers.