5/20/19

Population Medication Management Services Improve the Value of Patients’ Treatment and Health Outcomes

Where We Stand:

Patients today increasingly rely on medications as an important component of managing long-term chronic conditions, including cancer, diabetes, rheumatoid arthritis, and other disease states.

New and innovative biopharmaceuticals, including biologics and other specialty medications, are constantly being introduced in the United States to treat these and other conditions, but these often costly medications have raised both awareness of value and concerns about patient access and affordability of prescription medications. The value of prescription medications has increasingly become a focus of discussion for patients, prescribers, and policymakers concerned with managing health care costs and ensuring access to affordable and high quality treatments.

As medications continue to be more specialized, and in many cases more expensive than older medications, balancing access and affordability is important for patients, health care providers, and public and private health care payers. Use of appropriate medication regimens, regardless of cost, may help to improve patients’ conditions, improve quality of life, and lower other health care costs. The responsibility for ensuring appropriate medication selection applies to decision makers in health plans and other systems that manage patient populations, as well as the individual treatment providers. However, if patients do not use medications appropriately, the result is not only unnecessary spending on medication costs, but also the potential for increases in other health care costs because of the need to provide additional medical interventions or manage side effects.

Pharmacists, physicians and nurses who work in health plans and other settings focused on population health are an important part of the solution. Indeed, these health professionals are highly trained to develop and administer medication management services that identify gaps in care and optimize medication use for patients. These same medication management services, which health plans have provided for many decades have now expanded to accountable care organizations (ACOs), integrated delivery systems (IDS), and other alternative care models. Best practices and services developed by pharmacists and other health care professionals in health plans, including medication therapy management (MTM) and evidence-based formulary development, aim to ensure that all patients receive the medications they need to improve their health while at the same time moderating the rise of health care costs.

Population medication management services improve patient outcomes and increase the value of medications

Pharmacists are highly educated medication experts who consider each medication’s safety, efficacy and effectiveness before selecting it for use in a population or a patient. Today, pharmacists who work collaboratively with physicians and nurses increase the value of medications for populations by providing the following programs and services:

Designing and implementing MTM programs (led by pharmacists) to ensure that patients take medications effectively.
Designing evidence-based formularies that enhance quality of patient care by selecting the most appropriate medications for patients with the goals of reducing treatment failures, adverse drug events and hospitalizations and improving patient adherence and health outcomes. The formulary development process includes pharmacists working with other members of the health care team to evaluate the safety and clinical effectiveness of new medications in real world populations through ongoing medication evidence reviews. This process helps to ensure that decisions regarding medication use are based on appropriateness of therapy and not price alone. Formularies are a means to encourage patients to use clinically proven medications, determined to be more appropriate for a population managed by a health plan, ACO or IDS, through reduced co-payment or co-insurance. Exceptions to the formulary are available to patients when a non-formulary medication is appropriate based on a patient’s unique health circumstances. Pharmacists and other health care providers in health plans work with individual providers and patients to ensure appropriate medication selection.
Designing comprehensive evidence-based medication use policies to provide prescribers and patients with additional information for the safe and effective use of medications selected for the formulary.

Principles for improving value of medications

Support the autonomy and flexibility of health plans and other health-care decision makers to innovate and develop incentives and strategies, without undue external influence, that increase access to medicine and improve patient outcomes, while ensuring the prudent use of health care dollars. Such efforts can include decreasing patients’ out-of-pocket costs through lower copayments on generic drugs and certain preferred brands.
Encourage and facilitate the Food and Drug Administration (FDA) approval of biosimilars and interchangeables to provide patients with safe and effective alternatives to biologics, thereby promoting competition and increased access in the marketplace.
Support state and federal policies that encourage the uptake of biosimilar use and reduce barriers to their market entry. Continue to support the use of generics and educate patients and providers on the use and value of biosimilars and generics.
Ensure that patients continue to have a variety of network options of service locations to fill their prescriptions at the pharmacy of their choice – community retail pharmacy, mail service pharmacies and specialty pharmacies.
Allow pharmacists and other health care providers to design and implement MTM programs that meet the needs of populations without undue external influence.
Support federal and state legislation that recognizes pharmacists as health care providers. Provider status recognition would enhance pharmacists’ ability to work as part of the health care team through further participation in collaborative practice agreements and work directly with teams of physicians and nurses in ACOs, IDNs, and other arrangements.
Promote the adoption of laws, regulations, and guidance that encourage the use of real world evidence and comparative effectiveness research, based on competent and reliable scientific evidence, to compare prescription medications to each other and to other treatments to ensure that individual patients receive appropriate medications. For example, update provisions of the Food, Drug, and Cosmetic Act, such as Section 114 of the FDA Modernization Act and other provisions to promote communication of clinical and health care economic information between biopharmaceutical manufacturers and health plans and other decision makers.
Consider integration of the pharmacy and medical benefits to implement medication management resources that may help to drive efficiencies in the medical benefit. Allow Medicare Part B and other medical programs that provide medications to adopt utilization management techniques such as formularies, utilized under the pharmacy benefit to balance affordability and accessibility of medications.