If you’re a health system, you can no longer afford to silo drug management. Effective Pharmacy Benefit Management (PBM) engagement involves integrating the pharmacy resources that are available to the system that will flatten the cost-increase trend line and improve patient outcomes. A truly integrated pharmacy benefits solution gives health systems an advantage over traditional PBM models because they interact with every step in the patient journey—from administering the initial medication reconciliation review, to providing aspects of the benefit, to purchasing, dispensing and providing various types of patient follow-up.
When you consider PBM engagement in your health system, what matters most? The answer to that question will likely vary based on who is addressing the question. From a Human Resource (HR) perspective, HR administrators are most interested in the employee health plan. They have both costs and employee satisfaction to think about. The pharmacy division places value on network access which improves prescription volume and leverages purchasing advantages, while allowing the clinical pharmacists to focus on appropriate, cost-effective care for their patients. The C-Suite at a health system looks at the entire enterprise – where satisfaction, volume and risk management are critical components to enterprise success. Risk management arrangements with the system’s health plan partners rank high on the priority list for hospital leaders. As more health plans build risk relationships with health systems, the ability for system pharmacists to provide services that improve quality and lower costs is a key component in the overall risk relationship. Part of these services should be pharmacy benefit management functions which have traditionally resided in the health plan. It is very common for the PBM business model to be in direct conflict with a health system’s risk strategies, which is why a health system’s pharmacy department must take a leadership role in pharmacy benefits management for their own employees and their risk partners.
Before a health system can deploy an integrated risk strategy, they must understand their current PBM relationship. There are three basic PBM scenarios in which a health system may find themselves:
Having a fully integrated PBM does not imply that you will process your own claims and/or negotiate your own network agreements. PBM partner is still needed for operational tasks.
Untapped Resource: Clinical Pharmacy
As a health system, you may have an untapped resource in your clinical pharmacists. Integrating these valuable resources into your PBM strategy has huge advantages:
As a health system, your goal should be to provide a fully-integrated drug management solution that is seamless to patients, provides meaningful cost savings, increases pharmacy revenue and improves patient outcomes.
How do you go about accomplishing this with your existing PBM? Below are a few steps that can be taken to better understand your current environment.
To get started:
Understanding your health system pharmacy strengths and transforming these strengths into an overall integrated model is not impossible. You will need some specialized expertise from inside and outside your system. The integration of pharmacy and medical claims data is crucial to the construction of one coordinated approach that interacts with patients from end to end. With the spotlight on specialty pharmacy and its growing cost, it is time for health systems to transform their PBM strategy into fully integrated systems that move past the traditional, volume-focused approach and deliver true, value-driven solutions. PSG can support health systems in this evolution – from diagnosing the current state, to creating and acting on a strategic roadmap, to measuring your success.
PSG’s Sr. VP and Health Systems Practice Leader, Mike Medel recently hosted a webinar addressing many of the above concepts and recommendations. To view the recording, click here.
He can be reached at: [email protected] or at 972-624-7744