Prime’s High-Value Pharmacist Managed Care pilots win PBMI Excellence Award
Pilots achieve proven ROI for high-touch pharmacist services
September 15, 2021
These pilots leveraged the carve-in pharmacy benefit manager (PBM) alignment within the health plan and integrated medical and pharmacy claims from Prime’s industry-leading data and analytics tool. The pilots also demonstrated the importance of both PBM and health integration as well as data integration, to support successful managed care pharmacists working drug therapy optimization opportunities. Pharmacists use this care model and integrated data to conduct outreach to various stakeholders – health plans, providers, pharmacies, and members – depending on the most appropriate method to achieve a successful intervention. The guided interventions promote safe and cost-effective medication use such as: reducing instances of duplicate therapy, optimizing the drug therapy regimen, identifying suspicious utilization and evaluating various cost savings opportunities.
Prime saw great success with these pilots:
- In 2020, a Prime pharmacist embedded within the health plan team was dedicated to analyzing the plan’s specialty claims data, identified many provider and member intervention opportunities. These interventions resulted in a more than 3:1 return on investment. The specialty drug savings netted this plan $2.7 million in health care cost savings in one year alone.
- In 2019, Prime’s pilot assigned one full-time managed care pharmacist to use an integrated medical and pharmacy data visualization tool to find approximately 1,500 members using specialty drugs. This pharmacist assessed the therapy regimens of those specialty members and found 365 members had a potential savings opportunity. Significant savings were realized from the pharmacist conducting outreach to various stakeholders.
- In 2017, the pilot focused on drug therapy optimization for members using specialty and HIV drugs and delivered a more than 3:1 return on investment
Specialty drugs are often the focus of the pilots’ opportunities because they are the fastest growing expense within both the pharmacy benefit and the medical benefit. Because specialty drugs have high unit costs are found on both benefits, have complex dosing/treatment regimens that change over time, and carry the potential for fraud, waste and abuse (FWA), their use requires close oversight and review by managed care specialty pharmacists. The average annual cost of specialty medications can even put members in a “drug super spender” category (i.e., high drug-cost claimant defined as drug costs of greater than $250,000 annually). These high drug-cost claimants represent less than 50 per 100,000 commercially insured individuals and account for 10% of a health plan’s total drug spend.
To help maximize the efficiency and cost savings potential of the pharmacists, Prime uses it’s “super spender” predictive model to pinpoint those high-cost members.
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