The Employer’s Guide to Moving Beyond the Prescription to Repair the Process of Care

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No experience. Positive female pharmacist taking notes while mature male doctor using laptop

By Katherine H. Capps, Executive Director of  Get the Medications Right™ (GTMRx) Institute, the catalyst for change to medication management that brings together critical stakeholders across health care

Employers face a landscape for managing drug benefits that is more complex, and expensive, than ever before. Medications are involved in 80% of the way we treat and prevent illness; nearly one-third of all adults in the United States take five medications or more. Add in that the cost of prescription drugs increases every year—prescription medications account for one dollar out of every four dollars spent—and it is no surprise that employers across the country are feeling the pain.

With over 10,000 medications available on the market, a new way to manage medications is critical. What if your company could take on those complexities with an entirely new, innovative and proven approach? There is a roadmap, backed by evidence, ready and waiting for employers who are willing to move beyond managing the price of the pill by focusing on the process of care.

That’s the big idea behind comprehensive medication management (CMM), a personalized care process to improve clinical outcomes, increase patient satisfaction and reduce waste intended for all patients, not just those who are high-risk.

Right Medicine. Right Patient. Right Dosage.

CMM is a systematic, evidence-based approach designed to manage medication therapy problems, and it begins by determining whether the medications are right for the individual. This person-centered model of care is ordered by a physician who is working in collaborative practice with a clinical pharmacist who in turn works with the entire health care team and the patient to evaluate all medications and their impact on the individual.  

The patient assessment considers not only prescription and nonprescription drugs, but also vitamins and supplements as well as alternative medicines and the medications’ impact on their clinical status. The approach determines whether each medication is appropriate, effective and safe for that individual. Some medications may be stopped, others may be changed and others may be added to ensure that the clinical goals of therapy are being met. It’s like a medication check-up.

What Is Different about CMM?

CMM recognizes that appropriately skilled clinical pharmacists – given authority through collaborative practice agreements (CPAs) with the physician – can adjust, change or stop medications to meet clinical goals of therapy. Optimizing medications – and ensuring appropriate use — improves outcomes, saves lives and can reduce total cost of care.

CMM moves beyond focusing on the pill and instead focuses on the effectiveness ensuring the individual is taking the right medication to achieve the physician and patient defined goals for that medication. The clinical pharmacist considers medication dosage and use patterns, ensures that the patient understands their medications and can take them as intended and assesses that their own unique genetic make-up does not get in the way of effectiveness. The achievable goal is fewer medication misadventures, such as wrong drugs, wrong dose, drugs that make you sick or those that are just wrong. Companies can achieve better results for their health care spend.

Step onto the Path of Increased Efficacy and Efficiency

It isn’t difficult to become a stakeholder who creates change. The ultimate goal is to ask vendor partners to provide this service. Here are three steps employers can take now to make this goal a reality:

  1. Know What You’re Asking For: Arm yourself with knowledge ahead of discussions with your vendors. Medical carriers, pharmacy benefit managers (PBM) and the like may not be familiar with CMM. Ask them to share their solutions that are designed to manage medication problems that move beyond adherence programs and be open to pilot programs designed to meet the goal of managing medication misadventures on an ongoing basis. Ask your medical carrier, third party administrator and PBM to work with you to create trend reports that identify those members in greatest need for CMM services and track their progress.
  1. Align Internally and Get Buy-In: Use the data you’ve gathered to gain leadership support within your organization. CMM averages a return on investment around 3:1 to 5:1 the first year, something that may make the sell-in more attractive for your C-suite. Once you have buy-in from the top, ask your brokers to identify new products and services designed to manage medication therapy problems through CMM.
  1. Use Your Contract Authority and Make Your Move: Be prescriptive in designing contracts to center optimized medication use as an overall patient care and health benefit strategy; use the benefit plan design to shape vendor response and encourage innovative product solutions. Finally, be sure to work with your employer health care coalition and work with primary care providers in your community to identify how you can support advanced primary care services designed to optimize medication use reimbursed through your medical plan design.

Move beyond focusing on drug rebates, restrictive formularies and adherence programs.  Challenge your medical carriers, PBMs and other vendors to provide services that ensure that those medications you are paying for are safe, effective and appropriate. It is your fiduciary responsibility to have someone asking: Is this the right medication (or combination of medications) for my employees?