Integrating your company’s medical and pharmacy benefits can help your employees improve their health and lower costs.
“Integrating medical and drug management is a core competency of how to best manage diseases,” says Sarah Marche, senior vice president of Pharmacy Services at Highmark Blue Cross Blue Shield. “When you integrate benefits, you improve disease management for patients, driving better clinical outcomes, lowering medical and pharmacy costs, and simplifying processes, which leads to improved benefits administration for the customer.”
Smart Business spoke with Marche about how bringing your company’s medical and pharmacy benefits together under one organization can improve medical outcomes for your employees and lower costs.
How does integrating benefits work?
Companies with self-funded plans — in which the employer assumes the financial risk for providing health care benefits to employees — have the ability to use their insurer, in some cases, for their prescription benefits, as well. Alternatively, they can carve that pharmacy benefit out to a Pharmacy Benefit Manager (PBM).
Keeping both parts with one entity leads to better clinical outcomes because that entity has access to all of the patient’s medical and pharmacy data in real time. That allows for more effective, comprehensive disease management and can also lower costs for the client. There are drugs covered under the medical and pharmacy benefits. When you integrate benefits, your carrier can optimize the use of drug management and align policy coverage across the benefits, ensuring that members get the most clinically and cost-effective drug for their needs.
There are also administrative benefits, as members have one ID card for both pharmacy and medical coverage. Too often, when pharmacy benefits are carved out, patients are left stuck in the middle, not knowing whether a drug is covered under the medical plan or under the PBM. Having an integrated plan gives patients the ability to contact one customer service entity to make inquiries about all aspects of their care.
Is there an argument against integration?
PBMs will say a company that offers both medical and pharmacy doesn’t have the resources for both, and they may tell employers they can save more money with a company that focuses exclusively on pharmacy. However, that is a flawed argument, as organizations that offer both have dedicated experts, including nurses, case managers and pharmacists.
Multiple studies show the benefits of integrating medical and pharmacy under one provider. An independent study by HealthScape Advisors showed that Highmark customers with integrated medical and pharmacy benefits saved an average of $150 to $230 a year, compared to group customers with carved-out benefits, with savings driven by shorter episodes of care, enhanced chronic care management and increased member engagement. The study also showed that patients with integrated medical and pharmacy benefits reduced the average length of inpatient hospital stays by 3.9 percent, compared to those in groups with carved-out pharmacy benefits, and that they were 14 percent more likely, on average, to engage in care management programs.
Not one PBM has similar studies showing that costs are lowered by carving out the pharmacy benefit.
How does an insurer having access to real-time data benefit the patient?
The organization can see in pharmacy claims filed if someone hasn’t picked up a prescription yet. That means they aren’t taking their medication as prescribed, and the insurer can quickly intervene to prevent the exacerbation a condition that could worsen without the prescribed medication.
On the flip side, while a PBM has access to that same data, it cannot immediately act on it. Instead, it forwards it on to the medical benefits provider, but not in a timely manner. By the time the medical provider sees the data showing a patient is not compliant , it might be too late to intervene.
Whenever one organization has access to all data, both medical and pharmaceutical, in real time, it can immediately intervene when it sees gaps in care, driving better clinical outcomes and lowering costs.
Insights Health Care is brought to you by Highmark Blue Cross Blue Shield