How true value-based care begins with integrated benefits
Value. It’s the universal buzzword in health care today. From traditional health care stakeholders to new industry players, the value-based mission is the same: delivering the highest possible quality care for the lowest cost to the patient and to the health care system. One place where value-based innovations are particularly important is in the pharmacy. According to the Centers for Disease Control and Prevention (CDC), in the past 30 days, 48.9 percent of people in the U.S. have used at least one prescription drug and 73.9 percent of visits to a physician’s office ended with a script, resulting in 2.9 billion drugs being prescribed.
Prescription drugs are one of the most common interventions to manage chronic conditions. Given the volume and variety of drugs available, as well as the skyrocketing costs associated with brand-name and novel therapies, it’s no wonder that this area is ripe for value-based strategies.
As employers look to contain pharmacy costs for their employees while maintaining the highest quality of care, integrating pharmacy and medical benefits is poised to be the most effective strategy around.
Three ways integrating pharmacy and medical benefits can achieve value-based population health:
Seamless transitions between inpatient, outpatient, and at-home care
Judy was just discharged from the hospital after a three-night stay. Upon leaving, she was given a number of instructions from her doctor, a prescription for a new medication, and adjustments to her existing prescriptions. Prior to leaving the hospital, Judy met with a care manager to go over the information she received. A couple of days later, Judy received a call from a pharmacist who asked her about her current medications and side effects, answered Judy’s questions, and helped her set up an automatic refill for her prescriptions at her local pharmacy.
By integrating medical and pharmacy benefits, employees have access to a wide variety of resources that can ensure continuity of care. Providers, care managers, and pharmacists all working from the same set of integrated information means employees receive consistent, high-quality coordinated outreach, advice, and guidance about their condition and how to best manage it from one care setting to another.
Proactive care management to manage health risks
Tracey recently enrolled with a new insurance plan that had integrated pharmacy and medical benefits. A few weeks later, before her first doctor’s appointment, she received information from her insurer regarding a variety of programs included with her benefits that she could take advantage of to help her better manage her diabetes.
Pharmacy claims provide care managers with near real-time information on an individual’s specific health needs. For new enrollees, this information can generate insights long before their first interactions with providers and long before their medical claims are processed. Early insights generate proactive care management strategies such as highlighting specific care management programs for the management of chronic diseases or outreach from a care manager to discuss conditions for which the individual may be most at risk.
Optimizing individual patient care
Mike recently had his first call with his health coach, Shawn, who was going to provide him with some techniques to help him manage stress. One of the first things Shawn did was confirm all of Mike’s current medications. Seeing more than five, Shawn scheduled Mike an appointment with a pharmacy care manager for later that week.
Every person interacts with a health care system differently. Integrating medical and pharmacy benefits can map this journey and utilize it to create efficiencies in care management workflows. In an integrated environment, risks can be flagged and reviewed by care managers. For instance, a high number of prescription medications can trigger a review to investigate possible contraindications, adverse interactions, or availability of less expensive alternatives. Using the information from these interactions can help providers, care managers, and pharmacists tailor interventions and prescriptions for an individual employee’s needs while maintaining the safety and efficacy of the treatment plan.
At UPMC Health Plan, we offer a market-leading combination of pharmacy benefit management administration; provider-led formulary and pharmacy program development; innovative specialty pharmacy care management programs; and more to ensure a clinically integrated, whole-person care model.
Want to learn more about what we’re doing? Download our Pharmacy Capabilities brochure.
 (Centers for Disease Control and Prevention (CDC), 2017)