Industry Voices—The growing role of pharmacists in driving down drug costs through transparency

This is the third in a series of articles that looks at the current state of drug cost transparency for prescribers, pharmacists, and patients. The first two articles can be found here and here

The first and second articles in this series focused on the promise and challenges with real-time prescription benefit (RTPB), including the need to move beyond transparency solely when ordering new prescriptions through the electronic health record.

This third article expands the focus of drug cost transparency to include all of a patient’s current medications and all relevant points of patient care and communications.  While cost transparency to prescribers in EHRs is essential, there are many other relevant and important stakeholders in the care and communication processes, including the patients themselves. 

Pharmacists play an essential role in patient care in every care setting. They are clinically trained to identify opportunities to optimize medication use, and their dispensing experience uniquely prepares them to identify opportunities to improve drug cost for patients (with or without insurance) and for health systems.

Physicians recognize the expertise of pharmacists and are willing to engage in a discussion if it helps their patients. In some states, pharmacists have the authority to make medication changes independently when working under a collaborative care agreement, much like nurse practitioners. In California, pharmacists who have Advanced Practice Pharmacist licensure may prescribe in accordance with the requirements of the law. Pharmacists’ clinical responsibilities include but are not limited to:  

  • Conducting medication reviews and resolving drug therapy problems as part of the Medicare Part D Medication Therapy Management (MTM), where the service is reimbursable for pharmacists.

  • Providing comprehensive medication management services to ensure safe, appropriate and cost-effective use of medications and that support treatment goals and clinical quality improvement, such as medication adherence, measures in the CMS Star Rating system.  

  • Responding to patient medication inquiries, including cost concerns. 

Drug cost transparency also supports value-based care models, such as those in managed care and accountable care organizations (ACOs), that align health system incentives behind cost-effective care, including medications.

Many managed care organizations and ACOs employ pharmacists involved in population health initiatives and who support the organization to achieve performance goals. Making RTPB available to these pharmacists empowers action. Others in provider organizations, such as population health teams, other healthcare team members and medical office staff have limited tools in their workflows to help improve the cost of medications for patients. Pharmacy claims history, payer formularies and phone calls to pharmacies are often the only tools available to identify more cost-effective therapy opportunities.

Worse still, these instruments cannot provide patient-specific information that takes into account the patient’s health plan benefits to identify lower-cost alternative medications in real time. Without this information, most providers struggle with the idea of changing existing medication regimens that are accompanied by a discussion with the patient regarding the cost savings and the clinical aspects of the change in therapy.

An optimal system would automate the identification of dose-mapped and formulary-aligned alternative medications and provide patient-specific savings for each potential alternative.  

Drug cost transparency with a focus on identifying lower-cost alternatives is highly synergistic with pharmacists’ activities. Affordability is a major factor in medication adherence, a primary quality improvement focus for all stakeholders. When pharmacists engage in medication safety and quality improvement conversations with members and providers, medication cost discussions can be a natural tie-in to help improve medication adherence and patient satisfaction with their healthcare service.

In practice, robust drug cost transparency delivered at multiple points across the continuum of care and communication is showing solid results. Horizon Healthcare Services, Inc., New Jersey’s largest health insurance company, is generating savings by providing drug cost transparency services in the context of MTM and other provider and member touch points via an interactive application called MedOps. 

“Providing lower cost therapeutic equivalent alternative medications to key members of the care team beyond prescribers empowers the team and reduces drug costs for members,” noted Saira Jan, Horizon’s vice president and chief pharmacy officer.

Blue Shield of California is leveraging managed care pharmacists in multiple settings, from provider groups to virtual pharmacy partners and their own internal pharmacy staff, and generating drug cost savings for members by providing automated identification of dose-mapped and formulary-aligned alternative medications.  Blue Shield is achieving these savings for members and success by providing the MedOps application to pharmacists.

In addition, as recently announced, medication intelligence company Arine has begun embedding drug cost and alternative savings information into its medication intelligence platform to provide Blue Shield care teams with actionable medication optimization insights that improve health and economic outcomes.

“The drug cost data in context with clinical, social, and behavioral data drives our platform artificial intelligence (AI) to personalize our medication recommendations even further to overcome cost barriers while averting complications and keeping members healthy,” said Yoona Kim, Ph.D., co-founder and CEO of Arine. “This multifaceted approach helps create a healthcare system that is equitable for members and sustainably affordable for all healthcare stakeholders.”  

By collaborating with pharmacists and other members of the care team at key provider groups, with partners and internally, Blue Shield has created automated tools to identify the most cost-effective medications at every point of care.

Alison Lum is vice president of pharmacy services at Blue Shield of California. Edward Fotsch, M.D., is CEO of Gemini Health.