The topic of chronic disease management has received significant attention from health plans , especially in light of The Affordable Care Act. Mainly the discussion has centered around the increasing cost drain on the healthcare system and how to control this cost. Pharmacy benefits management, wellness, and disease management programs are some of the tools used by insurers and plan administrators to control health care costs. These programs are often misunderstood by plan participants as intrusive and burdensome because they are viewed as impediments to receiving the immediate care and benefits patients expect. Unfortunately, these perceptions overshadow the real benefits they provide the consumer.
On the front lines of the war on chronic disease management, how will the health plan empower the patient to help him or herself? How do we come together to take care of ourselves and each other? The dissemination of education about draining costs on a system and tools for chronic disease prevention is a very necessary part of the solution. However, the discussion should be centered around how various health plan programs help the consumer and change the perception of the health plan as foe to that of patient advocate.
What is Pharmacy Benefits Management (and Why Should We Care)?
According to URAC (Utilization Review Accreditation Committee), they define a pharmacy benefit management (PBM) company as:
…a third-party administrator of prescription drug programs. It processes and pays prescription drug claims, develops and maintains the formulary, contracts with pharmacies, and negotiates discounts and rebates with drug manufacturers.
Your only experience and understanding of PBMs may have been in the way of complaints over a lack of coverage for certain specialty prescriptions, but you probably had no idea why certain Rx “watchdogging” is put in place. Yes, there is no denying that prescription management programs are there to control costs, but in some cases these programs have helped saved lives. As greater numbers of drugs have been developed (and will continue to be developed) to treat health issues, higher costs result, leading to more cost and utilization control from health plans. Since these cost control measures will only become more prevalent, it’s important to know what they do. Says the Centers for Disease Control:
The cost burden of chronic illness is projected to grow to $4.2 trillion by 2023. Pharmacy benefit management programs and services should be a critical part of any strategy for managing the cost and quality of care associated with chronic diseases.
Additionally PBMs collect important data about specialty drugs. This data often plays an integral role in deciding which drugs stay on the market. While many critics have asserted that a PBM is only about saving the insurer/health plan money and does nothing to benefit patients, some of that criticism doesn’t paint the whole picture. In some cases the physicians aren’t privy to such data – they are human and can only process so much information, just like the rest of us. Your experience may have been that generic drugs must be used ahead of the newest brand name medications or you must endure a lengthy approval process for a specialty medication. Many patients understandably complain about these burdens. But in the case of certain high recognition drugs” like Vioxx or Celebrex, such utilization controls benefitted many patients and actually saved lives. The challenge for plans is to create a positive perception of these interventions, basically moving the dial from plan centered to patient centered endeavors.
Wellness and On-Site Care: A Solution?
As the evolution of chronic disease management continues, many corporations and insurance companies have now partnered to implement wellness programs that provide education, fitness discounts, smoking cessation, and nutrition counseling to prevent diseases before they occur. Additionally more and more companies are partnering with the medical community to even offer onsite health care. The evolution continues.
Although not enough employees take advantage of employer-sponsored wellness intitiatives, according to The Institute for Health Care Consumerism, there is evidence that employee satisfaction is linked to wellness programs.
… an online survey of more than 1,800 benefits decision-makers and more than 6,100 U.S. workers. Compared to workers who are not offered wellness programs, employees who…participate in them are more likely to have a higher level of job satisfaction, feel happier with their employer, and be more satisfied with their overall benefits.
How do you get employees to participate? The challenge for employers is to make these programs about the employees and not the employer. Wellness is no different than any other consumer product. The employee participates (buys) because of what’s in it for them.
Bridgeport Benefits is Part of the Solution
Bridgeport Benefits has spent the past 25 years perfecting the way we manage and employee benefits in greater Los Angeles, Nevada, and throughout California. Bridgeport provides the flexibility, choice, and resources necessary to lower the bottom line and better manage health care.
For more information on any topic covered in this article or how Bridgeport Benefits can be a resource for you, contact us today for a consultation. Put your company on the right track by keeping costs manageable but most importantly by promoting wellness.
 The Changing Role of Pharmacy Benefit Administration in Managing Chronic Conditions
by Allan Zimmerman
 The Evolution of the Management of Chronic Illness
by Michael Cryer, M.D. and Jim Winkler
 University of Missouri St. Louis
An Overview of Pharmacy Benefits Managers: Focus on the Consumer