Pharmacy benefit managers (PBMs) play a crucial role in managing prescription drug benefits for health plans and employers. Congress just made their jobs trickier by advancing a series of healthcare measures at the end of May to promote price transparency in Medicaid. Pressure is coming down on PBMs to curb pharmaceutical costs — even when the market drives those prices higher.
Total prescription drug spend is expected to go up by 6% to 8% in 2023, with consumers bearing the brunt. Those spending hikes mostly come from the growing demand for just a few branded drugs: market leaders like Humira for autoimmune disorders, Apixaban for cardiovascular disease, and blockbuster weight loss drugs like Ozempic and Wegovy for type 2 diabetes and obesity.
As healthcare costs continue to skyrocket and more payers scrutinize the cost-effectiveness of medications, PBMs are being challenged to find innovative and cost-effective treatments. They’re looking toward virtual care solutions that take a holistic approach to care, target and engage high-risk patients, and optimize medication treatment and adherence. With over 40% of Americans suffering from cardiometabolic diseases like diabetes, obesity, and heart disease, PBMs will want to look into solutions specializing in those complex, interrelated conditions.
Cardiometabolic solutions can help curb costs
Here are five reasons why PBMs should consider partnering with virtual cardiometabolic solutions and what both stakeholders stand to win.
Holistic approach to cardiometabolic care, paired with medication
Virtual cardiometabolic solutions help organizations get a handle on expensive conditions like obesity, diabetes, heart disease, and related risk factors. These platforms combine 1:1 video conferencing, data analytics, and personalized interventions to give a holistic view of people’s cardiometabolic health. By partnering with virtual solutions, PBMs can be sure people get coordinated care, including medication management, prescribing/deprescribing, intensive behavioral therapy with registered dietitians, remote monitoring, and patient education. This blended approach can lead to better adherence, improved health outcomes, and ultimately, cost savings.
Enhanced medication adherence
It’s hard to get people to take their medications consistently. Virtual solutions help by giving reminders, educational resources, and personalized interventions. Integrating medication management features within the virtual platform allows PBMs to help patients stay on track with their prescribed medications. Improved adherence leads to better health outcomes, reduces hospitalizations and complications that come with poorly managed cardiometabolic conditions, and allows for step down or titration of medication as appropriate over time.
Real-time data insights
Virtual cardiometabolic solutions use apps that sync with remote monitoring devices to collect real-time data on patients’ vital signs, biomarkers, and lifestyle behaviors. This continuous data stream offers a closer look into patients’ health status to help catch issues early and personalize interventions. PBMs can tap into this data to identify high-risk patients and optimize medication therapies. By proactively addressing health concerns, PBMs can help people avoid emergency department visits and hospitalizations, and save costs.
Personalized interventions and risk stratification
Virtual cardiometabolic solutions use algorithms and population-based analytics to personalize interventions. These platforms can stratify patients based on risk profiles and target interventions to those needing them most. They may also take a step therapy approach to treatment — starting with behavioral interventions, moving up to less expensive drugs, and primarily offering expensive branded drugs to those who most need them.
PBMs can leverage this capability to identify patients who may benefit from specific medication therapies, lifestyle modifications, or care management programs. By tailoring interventions to individual needs, PBMs can optimize treatment outcomes, minimize unnecessary spending, and achieve cost savings for health plans and employers.
Cost-effective population health management
Virtual cardiometabolic solutions offer population health management tools that can be invaluable for PBMs in optimizing medication formularies and controlling costs. By analyzing aggregated data from a large patient population, these platforms can identify medication utilization patterns, treatment success, and cost-effectiveness of different therapies. PBMs can use this real-world evidence to negotiate favorable contracts with pharmaceutical manufacturers, promote cost-effective medications, and design targeted formularies that prioritize evidence-based treatments. This proactive approach to population health management can lead to powerful prescription drug and total cost of care savings for health plans and employers.
A win-win for better outcomes and more cost savings
Partnering with virtual cardiometabolic solutions opens up a big opportunity for PBMs to deliver cost savings while improving patient outcomes for expensive conditions like diabetes, obesity, and heart disease. By integrating these innovative platforms into benefit design, PBMs can support holistic care delivery, enhance medication adherence, leverage real-time data insights, implement personalized interventions, and engage in cost-effective population health management. Together, PBMs and virtual cardiometabolic solutions can have a meaningful impact on health outcomes with more cost savings.
Alicia MacLeod is the VP of Payer, Provider, and PBM Sales at Vida Health. Alicia has more than a decade of experience in the payer and healthcare industry, where she has developed a deep understanding of the challenges and opportunities facing payer organizations in value based care and population health.