While the mainstream news frequently rings the alarm that the American public is “overprescribed,” employers continue to look for ways to optimize their pharmacy benefit — neither over-emphasizing prescription use nor discouraging employees from this vital benefit, but finding the “just right” approach.
Statistics from the Centers for Disease Control and Prevention’s 2018 report, Surveillance Report of Drug-related Risks and Outcomes, paint a startling picture in America:
As a large provider of health insurance coverage, employers have the opportunity to promote optimal pharmacy use and gain value with various strategies related to health plan design, disease management, workplace wellness, and advocacy programs offered by carriers and vendors. Employers stand to benefit because members who adhere to the right medication regimen can delay the cost risks associated with disease progression and other negative consequences, such as side effects and drug interactions.
A fundamental action that employers can take is to encourage and empower employees to be informed about their coverage and prescription options, and provide access to health literacy resources which are frequently offered by health insurance providers. Besides helping employees understand and appreciate the “hidden paycheck” that is their health and prescription benefits, employees can become more informed consumers.
More advanced and immediate strategies include leveraging the resources a benefits consultant, pharmacy benefit management (PBM), or health insurance provider can offer, such as:
Supporting Health Literacy and Advocacy for HR Management Benefit
Being diagnosed with a chronic disease or even worrying about having a disease can be an emotional and disruptive experience for anyone and can cause subsequent disengagement or even turnover from work. The more medications taken, the more likely risks will surface related to side effects or drug interactions which can impact PTO or leave needs. Therefore, there is benefit for employers from an HR perspective to:
Resources included or purchased from the carrier can help health plan members ensure that the medications they are taking are absolutely necessary and that there are no other behavioral or lifestyle changes that could be undertaken instead. This self awareness of needs for medications can also have positive financial consequences for members plan selection
When members are knowledgeable and focused on using the “goldilocks” approach to medications, they will be more informed about what they are consuming and better able to predict their out-of-pocket costs and potentially choose a plan that best suits their needs according to the 2019 Anthem Trends in Health Benefits report, 50% of employees do not know how to predict current or future out-of-pocket costs and 75% of employees feel “fear” regarding their healthcare finances. Just like doing your research for a big personal expense, when there is a mastery of the needs and reasons for consuming medications, there is generally a more judicious use of resources.
Chronic diseases and “The Lifestyle Prescription” to maximize value of prescriptions
Medication therapy may be medically necessary, but it has been found many times over that losing weight, exercising and/or living an active lifestyle, minimizing screen time and eating a nutritious and balanced diet can reduce the clinical indicators of chronic diseases, which are now being referred to as non communicable diseases (NCDs) — such as high blood pressure, diabetes and high cholesterol. Being overweight has implications for increased likelihood of cancer and joint issues in addition to contributing to the development of chronic diseases.
Many primary care doctors would initially encourage their patients to lose weight and change diet (remember those Cheerios and Quaker oatmeal commercials in the pre- streaming era?) as well as encourage them to watch and manage their children’s screen time. Employers can support members with chronic diseases by incorporating and encouraging wellness into their company culture and benefits. Additions as simple as adding in walking meetings, changing which foods are accessible in the cafeteria, leveraging wellness education resources, adding weight loss program discounts, gym memberships or disease management programs.
Behavioral health conditions and Synergistic Non Drug Management Approaches
Medication therapy for behavioral health conditions such as anxiety, depression and attention management may be medically necessary, but there are opportunities to use concurrent non-pharmacological lifestyle choices and activities to reduce the amount or total need for the medications. People experience positive changes in mood with the use of exercise, socialization and working out with friends. It is a best practice for those being medicated for anxiety and depression to receive concurrent talk therapy. Cognitive Behavioral Therapy (CBT) is recognized as an effective, beneficial to all and accessible approach to talk therapy and is therefore quickly being integrated into various behavioral health apps.
In the Midwest, “The Winter Blues” are common, and strategies such as light therapy, vitamin D supplementation and increased indoor activities with friends and family can help reduce symptoms. Many times, behavioral health concerns and chronic diseases go hand in hand, and behavioral health challenges are a barrier to the self-care necessary for chronic disease management. Employers can support members with behavioral health conditions with some of the aforementioned health and wellness additions, de-stigmatizing mental health via communication campaigns, enhancing EAP benefits or even offering access to counseling and or telehealth online apps.
Curbing Antibiotic over-prescription for the Benefit of All
Although it is usually a minimal source of spend, the overuse of antibiotics potentially has serious long-term effects for employers in the form of increased costs and mortality. The overuse of antibiotics is also contributing to drug resistant organisms. To date, according to the World Health Organization, a growing list of infections such as pneumonia, tuberculosis, blood poisoning (sepsis), foodborne diseases and gonorrhea are becoming drug resistant. Antibiotic resistant infections will make hospitalizations more costly, and the chance of surviving common infections less likely.
It is important that antibiotics are only prescribed for bacterial conditions and not for viral conditions such as the flu which, although miserable andat some times absolutely terrifying for parents with sick children, will subside with supportive treatment and rest. It is also important that, when prescribed, the full antibiotic course is taken even though symptoms have gone away. Antibiotics can also cause gastrointestinal distress, so why take them if they aren’t needed? For employers with on- and near-site clinics, ensuring that providers are judiciously prescribing antibiotics as well as educating members about this and other health topics can help combat antibiotic over-prescription.
Analytics support To Optimize Drug Utilization
A key role of insurance carriers is to negotiate pricing for drug and medical networks as part of the carriers administering whatever plan an employer group might want to deploy for its members. Therefore, carriers generally have powerful analytics capabilities and large staffs of medical professionals who can provide technical interpretation and solutions. ABRC also has similar clinical resources on staff and the Associated Intelligence analytics engine to provide in-depth, individualized and objective interpretations and solutions. If you are wondering if there might be some misuse of medications, your carrier and/or ABRC broker can be a resource.
Wellness apps and care management programs To Optimize Drug and Treatment Utilization
Many carriers deploy nurses and/or have disease and care management applications that can help members organize and adhere to their medication and healthy lifestyle choices. Using these apps or person-to-person resources, members can improve their diseases and lessen the need for medications. Depending on your population’s tendencies (whether they prefer to speak in-person or use the phone), you may end up deploying a specific solution.
Step therapy to Reduce high-cost medication Spend without Sacrificing Effectiveness
Immune modulator specialty medications such as Humira and Stelara can cost self-insured plans beyond $80,000 per year per members. The medications suppress the immune system which may be attacking joints (rheumatoid arthritis), skin (psoriasis), or GI system (Crohn’s Disease). However, when a person is initially diagnosed, less expensive immune modulating drugs can be tried first. Ensuring that the member is using the most cost-effective and clinically-effective medication can become the responsibility of the carrier. Beyond up-front cost savings, reducing the risk of adverse side effects and reactions that are associated with some immune modulation drugs can potentially prevent costs.
Formulary: Value in volume and efficacy
Similar to step therapy, formularies aim to influence members to consume medications that are the most cost and clinically effective. Generally, 3-5 tiers are created and the higher the tier, the more cost sharing the employee must face. However, risks faced with using formularies is that members who need certain (more expensively tiered) medications will pay more out of pocket. Also, formularies can be influenced by costs and business considerations more than clinical outcomes with employees requiring specific medications in the crosshairs.
If you have questions about prescription drugs and their impact your health plan, please contact us.
Anna is responsible for creating tailored, client-specific solutions supporting the overall health of employee populations. She is passionate about assisting large- and mid-sized employers to manage increasing plan costs, improve health outcomes and promote healthy and engaged employee populations.
Anna is responsible for creating tailored, client-specific solutions supporting the overall health of employee populations. She is passionate about assisting large- and mid-sized employers to manage increasing plan costs, improve health outcomes and promote healthy and engaged employee populations with broadbased and state-of-the-art interventions. Anna’s specialties include strategic health management consulting, care management and coordination, program management, provider relations, clinical performance improvement, promotion of health and wellness programs and population health management.
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