ACHI: pharmacy plan might improve healthcare results, lower cost

Pharmacy plan management might improve healthcare outcomes and limit pharmacy costs, according to the Arkansas Center for Health Improvement.

“As more citizens gain access to healthcare coverage, cost-effective delivery of healthcare services including pharmaceuticals is critical,” according to an ACHI fact sheet. “Pharmaceuticals are an increasing driver of costs, and employers and health plan administrators have emphasized the need for management of prescription drug benefits.”

Pharmacy plan management can be “integrated with existing primary care management models,” and “other value-oriented population-based strategies. This kind of integration with physicians and patients can lead to more timely identification of high-risk individuals, increased appropriate use of drugs or alternative therapies and improved health outcomes.”

Traditionally, pharmacy plan management has included “price negotiation, the substitution of generic drugs in place of higher-cost alternatives, rebates from manufacturers, beneficiary cost sharing, formulary or drug list restrictions, disease management, mail service prescriptions and drug utilization review,” according to the fact sheet. “Disease management and population-level management tactics” are becoming more popular “in an effort to improve patient outcomes and contain cost growth.” Disease management involves “identifying high-risk patients with chronic or special conditions for whom intensive medical care and pharmaceutical management is beneficial.”

The management programs commonly reduce cost using a tiered formulary or reference prices. The tiered formulary gives patients treatment options or drug choices. Most drugs on the low-tier are generics and typically cost less. Those on the higher-tier cost more but are brand name or specialty drugs.

In 2015, 81% of workers’ health plans included three or more tiers of cost sharing. And, 23% of the workers had plans with four or more cost-sharing tiers, up from 13% in 2010, the fact sheet shows. “While tiered formularies are aimed at reducing drug spending for payers, increased member cost sharing may lead to patient non-adherence or adverse outcomes.”