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Embracing pharmacy care management for high-value care delivery

Pharmacists have become a critical part of healthcare delivery.

By Laureen Biczak, Medical Director, Change Healthcare (formerly Goold Health Systems)

The recognition of pharmacists' important role in clinical care has been trending higher in recent years, and for good reason. Pharmacists have the right knowledge and are positioned to positively affect care in today's quality-driven healthcare climate.

Industry groups are increasingly recognizing the role of effective medication management in achieving clinical benefits while lowering costs. Two important trends that are affecting patient health outcomes and cost of treatment are medication adherence and the rising cost of both brand name and generic drugs.

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To combat the $290 billion in annual expenses associated with non-adherence in the United States1, many payers and pharmacies are turning to pharmacy care management. Industry statistics specifically reveal that only 68 to 75 of every 100 prescriptions are filled by patients2 and only 25 to 30 are properly taken,3 creating significant risk in terms of optimizing patient outcomes and realizing a return on investment for high-cost medications. As the industry works toward providing value-based care (rather than volume-based care), these types of behaviors can adversely affect quality and cost goals.

For example, a patient with hepatitis C may leave a pharmacy with a prescription that is very efficacious but with a high sticker price of $30,000. If the patient does not take the medication as indicated, the value proposition of clinical benefit outweighing the medication's high cost is not realized. It also can be very difficult for providers and pharmacists to realize the long-term quality of care.

How pharmacy care management helps

Pharmacy care management enables patients to receive medication consultation and information immediately upon authorization to allow prescribed therapies to be understood before the first dose is consumed. Not only is the pharmacist who provides care management able to immediately evaluate whether a drug conforms to the patient's medical needs, but they are also able to educate and follow the patient through each step of the care timeline.

The reality for payers and pharmacies is that today's authorization systems are generally not designed for value-based care models. There is often only a snapshot of patient demographics provided when high-cost medications are authorized, but caregivers need access to more personalized data to develop an effective care plan. Pharmacy care management provides extra analytics and clinical support to optimize medications and allow patients to realize the full benefit of their therapies.

Consider the Medicaid system

Medicaid case managers struggle with the resources to effectively manage chronic disease and safety net programs. Compounding this issue is the fact that Medicaid is generally required to accommodate all medication needs, regardless of cost.

When a pharmacy care manager is linked to a Medicaid case manager to focus on tactics for medication success, the potential impact on quality outcomes can be significant because pharmaceutical clinical expertise is added to the equation. Plus, pharmacy care management services that leverage the latest technology can manage patients in real-time by identifying those who are not following through with prescriptions and refills.

One organization that serves a large Medicaid population leveraged pharmacy care management services beginning in 2013 to focus on education, adherence and proper use of medications among nearly 600 of its 300,000-plus members. With the right technology infrastructure in place to support direct contact between pharmacy care managers, prescribers and members in real time, the organization has achieved nearly $2 million in direct cost avoidance savings annually since adopting the program four years ago.

Pharmacists have become a critical part of healthcare delivery. Pharmacies that capitalize on the unique knowledge base of their clinicians and the expertise that these professionals bring to care delivery can have greater success in moving the needle on outcomes and performance in the value-based healthcare landscape.

Laureen Biczak, Medical Director, Change Healthcare (formerly Goold Health Systems)

© 2017 Change Healthcare Operations LLC and/or its subsidiaries or affiliates. All Rights Reserved.


1. New England Healthcare Institute. "Thinking Outside the Pillbox," A NEHI Research Brief, August 2009.
2. Fischer MA, Stedman MR, Lii J, et al. Primary Medication Non-Adherence: Analysis of 195,930 Electronic Prescriptions. Journal of General Internal Medicine. 2010;25(4):284-290. doi:10.1007/s11606-010-1253-9.
3. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005 Aug 4;353(5):487-97

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