In the past year and a half, differences in the US health system have become the focus of attention. We know that there were differences before Covid-19, but the pandemic has issued an undeniable call to action. What steps will we take to build a fairer health system?
Although the pandemic has exposed major shortcomings, the crisis has also demonstrated the resilience, determination and dedication of healthcare workers. Providers have discovered innovative ways to care for patients who need them. Now, we must seize this momentum. We must reimagine the future of care and address the challenges that hindered health equity in the past. Pharmacy Benefit Managers (PBM) are in an excellent position to lead the way by accepting the principles of value-based care.
For a long time, compared with healthcare organizations, PBM business models have more in common with retail entities. As a “middleman”, dialogue has always been entirely dependent on prices, rebates and discounts-this is the problem. If people don’t know the latest trends in clothing or cars equally, that’s okay. However, healthcare is fundamentally different from retail. There should be no difference in access to pharmacy benefits.
Today’s PBM has a huge opportunity to help resolve health disparities by shifting current drug pricing and “cost and access” conversations to value-based discussions. They should consider how to provide the right medicine at the right time and at the right cost. The measure of success should be clinical results, financial results, and patient-centered care. PBM can do its part to create fairer and more comprehensive care in the following ways:
- Shift the focus from disease-oriented treatment to “whole person” care
- Eliminate access barriers through extensive networks and open prescription models
Strengthen holistic care
The Health Maintenance Organization (HMO) of the 1990s had difficulties, but they did one thing right: They allowed primary care providers (PCPs) to be patient care quarterbacks. PCP can understand the services that patients receive, which means that they can have a relatively complete understanding of the patient’s overall health.
As HMO was eliminated, condition-oriented clinical programs were replaced. Today, it is common for people with type 2 diabetes to participate in diabetes management programs, while people with chronic heart failure (CHF) are directed to participate in the CHF program. Sounds logical, right?
The problem lies in the fact that disease-oriented clinical projects lack a “quarterback” who has a comprehensive understanding of patients. By focusing on one major disease, they are often unable to deal with key underlying social, behavioral, and physical comorbidities that significantly increase clinical and financial risk. Take a patient with type 2 diabetes as an example. A disease-oriented diabetes program may zero in on healthy eating skills and weight management strategies, but it will never identify or resolve the patient’s comorbidities, hyperlipidemia and chronic kidney disease (CKD)-each of which may be clinically relevant And financial results.
PBM has a unique opportunity to become a de facto healthy quarterback because they can provide a missing 360-degree view of the patient. This is especially true if they operate under a value-based, pay-for-performance model that rewards active health management. Under this model, PBM is no longer encouraged to increase the number of drugs ordered.Instead, they are driven to achieve clear clinical with financial indicator.
This shift in focus makes a huge difference. It gives PBM a reason to invest in technology and work processes to proactively take care of the overall health of patients, not just their major diseases. It hires pharmacists as active members of the patient care team—cooperating with PCP and other providers. As long as the patient has population health data and insights, it will optimize a clinically appropriate treatment plan based on the patient’s unique risk profile. By looking at the entire patient, pharmacists can optimize utilization and improve results, thereby reducing costs.
Shift to an open access model
Pharmacy deserts are another cause of health disparities, and these problems must be addressed to achieve fairness.If we take Covid-19 vaccine management as an example, the data shows that it should be unacceptable 111 rural counties in the U.S. do not have qualified pharmacies to vaccinate against COVID-19However, it is not just rural residents who are suffering.The epidemic is also exposed The urban poor have no access to pharmacies.
Of course, there is nothing we can do about some aspects of the Pharmacy Desert challenge. But we can control whether policies and procedures restrict or open access to retail pharmacies. Why do we need network spin-off and reduced formulary to control costs?
Once again, adopting a value-based care model can simplify the path to greater equity—this time through open pharmacy access. The reason is simple: the value-based model recognizes that the long-standing “cost and access” dichotomy is flawed. It has not been proven that it can bend the cost curve or improve the quality of patient care.
So why is there a “cost and access” problem? What happens if incentives promote open access and active cost management instead of more prescriptions? The answer is clear: it will ensure that people get the drugs they need in the most convenient way for them, and may bring better compliance and downstream effects of results.
In fact, when the primary motivation is to improve clinical and financial results, human costs and access restrictions disappear. Every time we ensure that policies, procedures, and workflows revolve around true patient care, we add value to the healthcare ecosystem.
Equity starts with value
Compared with trying to alleviate the disease after it has developed, a proactive approach to holistic health is much better and cheaper. This is the underlying wisdom to promote value-based care throughout the healthcare continuum. PBM should also accept this concept.
Covid-19 reveals a huge opportunity to reduce the health gap by refocusing on providing value, which is by no means a simple feat. Reimagining a more equitable and people-centered healthcare system requires healthcare leaders to face the status quo. Nevertheless, it is possible.
We need to refocus on the whole person—not just their acute diagnosis. This means identifying and explaining comorbidities. This means taking a more preventive approach to care. We also need to make every effort to open pharmacy access and eradicate pharmacy deserts. If we do these things, we can start to replace the existing health gap with a fairer and healthy future.
Photo: Peter Pencil, Getty Images
