05/22/23

PBMs: Moving Beyond Cost to Care

WithMe Team

PBMs were not originally designed for care.

They were designed to help manage client costs.

And they are pretty good at it. Even as the role of PBMs has become more complicated and opaque in time, no one thinks a payer would save money by negotiating drug prices directly with the manufacturer.

But in the past few decades, the US healthcare landscape has changed. Doctors are under more financial pressure than ever, resulting in a healthcare system that often rushes patient interactions and makes accessing providers when we need them difficult. And even if you can get an appointment to see a healthcare professional, it can be expensive. Often too expensive.

So it has become harder to access healthcare providers - and we’re taking more medication. In the last twenty years, there has been a 200% increase in Americans taking more than one medication. Providers regularly prescribe a medication without having an exact picture of what other medications a patient is on. This lack of visibility into the “full medicine cabinet” greatly elevates the risk of adverse drug events. The Lown Institute reports that in 2018, over five million older adults sought medical attention for adverse drug events, with 5% ending in hospitalizations at a cost of $3.8 billion. Taking the right medication in the wrong way - or not taking it - is also costly. A 2018 National Institute of Health study estimated that preventable hospitalizations and death from non-optimized medication accounts for 16% of annual healthcare costs, or ~$524 billion in 2016.

To recap: Americans have more barriers to accessing healthcare providers but are taking more medications.

This is bad for pharmacy costs, for medical costs and for health outcomes. What’s the solution?

We believe: a better kind of PBM. One that is great at cost containment but also great at care.

Why a PBM? Unlike providers, PBMs have full visibility into a member’s medication. We can see all the different medications a member is on and assess whether they interact dangerously. We can see when a member starts a new medication that may be tricky to administer or have side effects. We can see when a member doesn’t fill a critical medication.

WithMe Health was designed from the group-up to care for members.

We are tech-enabled but human-led. mPath360TM, our proprietary technology, digests member data (including medical, rx, self-reported, and Social Determinants of Health) to build a highly personalized member profile and then combines this clear, real-time picture of the member with an ever-evolving in-depth clinical ruleset to prioritize interventions, undertaken by our Medication Guides.

And our Medication Guides are magic. They are pharmacist and pharmacist-techs who are highly trained in bio-psycho-social techniques so that they can connect with members, assess their needs as individuals, and together decide on next steps. This respectful, empathetic, and collaborative approach to behavior change works: ⅔ of our recommendations are accepted by members and providers. Our Guides are available to members 24/7.

MEDS


They can call a member who has been newly prescribed insulin and see whether, in the quiet of their home, they need any guidance on self-injecting. They will reach out to a member newly prescribed a biologic for rheumatoid arthritis and ask them, how are they feeling? Are they feeling as they should? They can answer questions about side effects: normal or cause for concern? In a recent interaction, our Guide called a member who hadn’t filled her inhaler on time. The member said that she went to pick it up and it was three times as expensive as the prior month. Our Guides found a coupon she could use to lower the cost.

Being able to meaningfully impact the medication habits of members helps curb pharmacy spend, which now accounts for 22% of premiums. We save our clients 29% vs. their previous spend - as validated by Validation Institution. And our pharmacy support also curbs medical spend, by avoiding adverse events caused by non-adherence or adverse drug reactions, or preventing disease progression through enabling adherence.

A PBM in the care business is good for members. But it’s also good for business.