As the healthcare industry continues to evolve, it is more important than ever to embrace strategies that improve outcomes, lower costs, and create a better experience for patients. One strategy that is gaining momentum is the integration of medical and pharmacy benefits.
At CarelonRx, we see every day how aligned benefits lead to better care. Integrating medical and pharmacy data creates a more complete view of a person’s health, allowing providers to intervene earlier, close care gaps faster, and personalize treatment more effectively. The result is improved safety and adherence, fewer hospitalizations, and a more efficient use of healthcare dollars.
Creating a connected care team
One of the biggest benefits of data integration is improved medication adherence. Each year in the United States, medication non-adherence is linked to 125,000 deaths and an estimated $100-$300 billion in preventable healthcare costs.
When payers and providers have a shared view of pharmacy and medical data, they can identify gaps in care and intervene earlier, before those gaps turn into poor health outcomes and costly complications. Integrated benefits also support a holistic approach to improving whole health. When providers understand barriers like transportation, food insecurity, or financial hardship, they can work as a connected care team to remove obstacles together.
For example, imagine Maria, who lives with diabetes and high blood pressure. A pharmacist within a pharmacy benefit manager (PBM) can see in Maria’s file that she hasn’t picked up her medications from her pharmacy in a month. She’s also missed her regularly scheduled doctor’s visit. Seeing these red flags, the PBM pharmacist reaches out to Maria and learns she lost her job and now lacks transportation. The pharmacist is then able to connect Maria with community resources for transportation so she can maintain her health check-ups and schedule her prescriptions to be delivered to her home. The pharmacist also connects with Maria’s provider to talk about these gaps in care and how the health team can work together to support Maria’s medication adherence.
Reducing costs while improving quality
For health and pharmacy benefits, integration offers a powerful opportunity to lower costs without compromising quality. Identifying the most cost-effective care settings and medications can help people access high-value services that are both clinically effective and financially sustainable.
An integrated model can also reduce unnecessary spending by preventing duplicate tests, minimizing adverse drug interactions, and streamlining care coordination. CarelonRx took a look internally at members who utilized CarelonRx for their PBM and Anthem medical benefits and found that integrating medical and pharmacy benefits led to significant cost savings.
This included over $100 per member per month in all-cause medical spending, more than $66 in inpatient spending per member per month, and over $50 in outpatient spending per member per month.
Additionally, when clinical insights are shared in real time, providers can make more informed treatment decisions that improve outcomes while reducing waste. For instance, integrating claims data with medication adherence alerts enables clinicians to adjust therapies proactively, avoiding complications that would otherwise lead to costly ER visits or hospital admissions. These efficiencies translate into tangible savings for health plans, employers, and, most importantly, patients themselves.
A smarter system for a better future
The integration of medical and pharmacy benefits is a commonsense approach to creating a healthcare system that is more connected, patient-centered, and efficient. It paves the way for a more dynamic, responsive system where care teams can focus less on administrative hurdles and more on delivering the right care at the right time. PBMs are uniquely positioned to lead this transformation by embracing models that align data, teams, and incentives.
The future of healthcare depends on collaboration, transparency, and personalization. Integrated benefits are not only a tool to achieve these goals, but they are also a blueprint for a more effective healthcare system that improves patient experiences.
Amy Mulderry is the president of CarelonRx, Elevance Health’s pharmacy benefit manager
