Pharmacists play an indispensable role in the healthcare system across a variety of settings – community pharmacies, primary care facilities, hospitals, health plans, and pharmacy benefit managers (PBMs).
Community-based pharmacists serve as a crucial link connecting patients, healthcare providers and health plan organizations. Their critical responsibilities encompass maximizing the safe and efficient use of medications, mitigating adverse effects by monitoring drug interactions, giving valuable education on medication usage, optimizing medications, and facilitating patient adherence, along with providing an array of other essential clinical healthcare services within their scope of practice.
Local community pharmacists are also highly accessible and trusted by patients. Research shows that individuals visit their community pharmacies almost twice as often as they visit their primary care physician or other healthcare professionals. Frequent, oftentimes face-to-face engagement, combined with the ability to reach populations that are underserved, make local pharmacists an essential partner in improving health outcomes.
Understanding the importance of community pharmacists in healthcare, Elevance Health and their PBM, CarelonRx, have partnered with CPESN USA pharmacies since 2021 to support Medicaid members in managing their asthma, chronic obstructive pulmonary disease (COPD), mental health, and opioid use disorders. Through this collaboration, Elevance Health/CarelonRx identifies clinically high-risk Medicaid plan members based on a set of criteria applied to pharmacy and medical claims data and then matches patients with local CPESN-affiliated pharmacies. The local pharmacist then contacts the patient directly to discuss enhanced services such as medication delivery, unit-of-use medication packaging, medication synchronization, social determinants of health screenings, health and wellness coaching, and provider engagement services. The local pharmacist schedules regular follow-up sessions with the patient and creates a personalized care plan empowering them to manage their medications and health goals. This program leverages the accessibility and interaction that local independent pharmacies have with Medicaid members.
As a result of this collaboration, we find there are three significant ways local pharmacists and pharmacists within PBMs can work together to improve health outcomes and enhance healthcare efficiency:
- Identifying and Supporting At-Risk Patients: Collaboration between community pharmacists, health insurers and PBMs is critical in helping patients improve their health and live healthier lives. Local community pharmacists are uniquely positioned to positively affect chronic disease outcomes through medication therapy management and other counseling services. Pharmacists at PBMs utilize data to identify patients needing enhanced clinical services and match those patients with local community pharmacists. For local pharmacists and PBMs to effectively identify and support at-risk patients, two-way communication is essential. The process starts with a pharmacist at the PBM analyzing available data to identify patients whose health is potentially at-risk. For our collaboration, these pharmacists are supported by a state-of-the-art analytics engine that helps pharmacists at the PBM target the right patients for the program. They then notify that patient’s community pharmacist who can intervene successfully with the patient. From there, the pharmacists work together to monitor the patient for improved health outcomes following the intervention. We recently witnessed the success of a collaboration with a patient in Maryland.
- Lowering Healthcare Costs: Healthcare expenditures are projected to climb steadily. Through our partnership, we discovered pharmacists can play an important role in lowering costs. For patients in the CPESN and Elevance Health/CarelonRx program, there was a decrease in members’ utilization in all categories of medical services, with the greatest declines in emergency department use (17.9 percent) and inpatient admissions (30.1 percent), leading to savings in overall healthcare costs in part due to improved medication adherence. Significant improvements in anti-anxiety medication adherence were observed among the 106 program participants with mental health conditions, with 29.2 percent of those members becoming adherent to their treatment plan following their participation in the program. Similarly, of the 83 members who started out not adhering to their anti-psychotic medications, 44.6 percent became adherent to their treatment plan, ultimately driving down healthcare costs.
- Achieving Industry-Established Care Measures: The collaboration between community pharmacists and pharmacists working at the PBM can improve quality scores, such as the Healthcare Effectiveness Data and Information Set (HEDIS), as well. For example, we examined the Asthma Medication Ratio (AMR), a HEDIS quality measure. Among the 137 participants whose pre-engagement AMR suggested they may be experiencing potential care gaps in their respiratory condition management, more than 41 percent demonstrated an improvement in their AMR or achievement of the desired AMR. Trends in reliever inhaler use by participating members with chronic respiratory conditions were also evaluated, with an 8.1 percent decline in reliever inhaler use among engaged members with chronic respiratory conditions.
Establishing collaboration between PBMs and community pharmacies is raising the bar for clinical services in an approachable setting. This patient-centric collaboration that reimburses the local, community pharmacist for providing impactful interventions holds the potential to emerge as a significant model for the future of effective, efficient, and sustainable healthcare delivery, directing us toward enhanced health outcomes for the most vulnerable populations.
Stacey Decembrele, MPH, is Staff Vice President of Pharmacy Network Management, Strategy & Contracting at Elevance Health; and Cody Clifton, PharmD, is Director of Practice Transformation and Clinical Programs at CPESN USA