The high cost of prescription drugs is one of the factors driving up U.S. employer health care costs.
Employers have spent years adjusting formularies, negotiating pharmacy contracts and introducing programs meant to manage utilization.
Those efforts still matter, but many of them come into play after a treatment decision has already been made.
An employer plan or its partners can intervene more effectively by telling a health care provider about clinically appropriate, lower-cost medication options while the provider is writing a prescription for a covered employee.
Opportunities for savings
Lowering pharmacy spending does not always require restricting access to drugs or making broad changes to drug benefits.
The existing plan formulary may already offer savings opportunities.
A review of clinical, claims and formulary information may show that a lower-cost therapy or biosimilar could be appropriate for a particular patient.
A review may also reveal opportunities to eliminate unnecessary prescriptions from a patient’s existing medication regimen.
Cost, however, is only part of the decision.
A less expensive medication is not automatically the right medication for every patient. Previous treatment response, medical history and other clinical considerations still matter. That’s why the prescriber must remain at the center of the process.
Communications timing
Timing can determine whether a savings opportunity leads to change: If a less expensive option is identified at the wrong time, the prescriber may miss the opportunity.
Many health plan and pharmacy partners can find opportunities to save money in a plan’s prescription data.
An effective partner that identifies an appropriate alternative should tell a prescriber about the alternative while the prescriber is writing the prescription and the information is still useful.
Ideally, the alert should provide enough context for the prescriber to understand why another medication is being suggested. That way, the prescriber can decide whether a change is appropriate without putting the employee in the middle and making the employee coordinate the conversation.
Clinician attention
Getting information to a prescriber is useful only if the information is relevant.
Clinicians already deal with a steady flow of administrative requests, coverage questions and alerts. Another notification that simply says that a medication costs too much is unlikely to be helpful.
A useful recommendation needs to be more specific. It should point to a lower-cost option that may be appropriate for the patient and give the clinician enough information to evaluate it in the context of the patient’s care.
Depending on the situation, that may include formulary information, a patient’s medication history or other relevant clinical details.
The physician can then accept the recommendation, choose another course or decide that the original medication remains the best option.
Keeping that decision with the prescriber is important. The goal is to identify unnecessary drug spending without creating another coverage hurdle or forcing patients to go through separate processes to obtain the medications that their clinicians believe they need.
Impact assessment
There is also a difference between identifying potential savings and realizing them.
A report might uncover hundreds of cases where a lower-cost option exists, but the number itself says little about whether those opportunities ever affected a prescription.
Employers need visibility into what happened after an opportunity was found.
Was the information sent to the appropriate prescriber? Did the clinician review it?
If a change was clinically appropriate, did the clinician make the change?
Most importantly, did the change reduce costs without adding unnecessary work for the employee, clinician or pharmacist?
Those questions give employers a better sense of whether a pharmacy strategy is changing spending in practice or simply identifying expensive medications after the fact.