It’s Time to Strongly Control Medicines at the Individual Level – MedCity News

It’s no secret that health care costs are rising at a rate that far outpaces inflation.

In fact, the average price increase in the US from 2008 to 2022 was about 45%, while employer spending on health care during the same period increased by more than 60%. Between 1962 and 2022, health care has increased from 5% to 17% of America’s GDP.

Not surprisingly, given the prominent role employers play in America’s health care landscape, and the financial burden they bear, companies are eager to find cost-cutting solutions.

This has led to an increase in health technology vendors that provide care for a variety of different conditions, including diabetes, musculoskeletal issues and mental health care. The goal of many of these companies is that the latest technology can connect patients and providers every time, providing the care, responsibility, and regularity that patients need to improve their conditions. The promise of these solutions is that doing so lowers costs.

Although this approach to proactive intervention at the individual level often leads to cost savings, it tends to ignore one of the biggest drivers of health care spending – prescription drugs.

In fact, while overall inflation in 2022 was about 4% and health care costs rose about 6%, prescription drug costs rose by more than 15% in the same year.

One of the biggest reasons for the rise in the price of prescription drugs in the last two decades has been the release of more and more “prescription drugs”. Fueled by massive marketing campaigns, these drugs fetch more than $1B in sales, in part because consumers actively seek them out.

Companies have partnered with pharmacy benefit managers (PBMs) to address these costs by establishing population-level controls such as prior authorization and formulary management. The problem is that there is still a lot of dirt that slips through the cracks of what is allowed.

And if the current GLP-1 craze has taught us anything, it’s that savvy consumers will find a way to qualify for a given drug if they want it badly enough, often leaving employers to foot the bill.

Although PBMs save a lot of waste by managing medications at the population level, any successful response to rising drug costs must manage medications at the individual level. situation.

Just because someone can take medicine doesn’t mean they should be.

In a typical employer environment, it is common to see about 25% of plan members on 5 or more prescription drugs. Because most people don’t spend a lot of time with their primary care physician, and because most people have a multi-doctor care team, it’s common for patients to end up with prescriptions. not only duplicative and destructive, but also potentially harmful compounds. worsening symptoms and leading to expensive hospital visits. Not to mention the fact that many drugs are prescribed specifically to reduce the dangerous side effects caused by another prescription.

Fortunately, when patients with complex conditions and a high number of prescription drugs have direct and frequent contact with a pharmacist, we see the same benefits – medical and financial – as the specialist. A dietitian, physical therapist, or psychologist is included in the individual care team. like many solutions that are prominent today.

With many of these solutions, however, it can be difficult to get patients to engage with their care team. Another benefit of active medication management is that patients not only get clinical help to manage and change their medications so they feel better and get better, they also save money on Costly copays add up – especially for those taking five or more medications.

In fact, enrollees save $1,100 annually, with more than 90% of their savings recognized by the plan sponsor.

The source of these savings is light. For patients, copay helps save 65% of member costs, and network transfers contribute 25%, and medical exchanges bring 10% of total costs.

On the plan side, a whopping 55% of cost savings came from treatment exchanges, and 40% from unnecessary drug discounts, and 5% from referrals to network pharmacies.

In addition to financial savings, including a clinical pharmacist on a patient’s comprehensive care team provides much-needed support to America’s primary care physicians who do not have the time or frequency to interact with patients to manage multiple medications. actively. When entrepreneurs recommend a prescription change, 86% of doctors accept those recommendations.

Indeed, this type of active medication management at the individual level is essentially an extension of what PBMs are already doing at the organizational level. By picking up where PBMs leave off, clinical entrepreneurs can help plan sponsors see cost savings and clinical outcomes on an individual level.

Photo: megaflop, Getty Images

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