It’s Time to Actively Manage Medications at the Individual Level

It’s no secret that healthcare costs are rising at a rate that far outpaces inflation. 

In fact, total US inflation from 2008 to 2022 was about 45%, while the amount employers spent on healthcare over the same period rose by more than 60%. Between 1962 and 2022, healthcare has grown from 5% to 17% of the American GDP. 

Unsurprisingly, given the prominent role employers play in America’s healthcare ecosystem, and the financial burden they shoulder, companies are anxious to find solutions that lower costs. 

This has driven a surge in health tech vendors that provide care for a wide range of conditions, including diabetes, musculoskeletal issues, and mental healthcare. The premise of many of these companies is that modern technology can connect patients with providers on a more regular basis, providing the care, accountability, and regularity that patients need in order to improve their conditions. The promise of these solutions is that doing so lowers costs. 

While this type of active intervention at the individual level does often lead to cost savings, it tends to overlook one of the biggest factors in healthcare spend — prescription drugs. 

In fact, while general inflation in 2022 was about 4% and healthcare costs rose about 6%, prescription drug costs rose by more than 15% that same year. 

One of the biggest factors in rising prescription drug costs over the last couple decades has been the release of more and more “blockbuster drugs.” Fueled by massive advertising campaigns, these drugs attain more than $1B in sales, in part because consumers actively seek them out. 

Companies have partnered with pharmacy benefit managers (PBMs) to get a handle on these costs by instituting population-level controls like prior authorization and formulary management. The trouble is there’s still a lot of waste that slips through the cracks in what’s allowed.  

And if the current GLP-1 craze has taught us anything, it’s that savvy consumers will find a way to qualify for a given drug if they want it badly enough, often leaving employers to foot the bill. 

While PBMs keep a lot of waste at bay by managing medications at the population level, any successful response to skyrocketing drug costs has to also actively manage medications at the individual level. 

Just because someone can be on a given medication doesn’t mean they should be. 

In a typical employer population, it’s not uncommon to see around 25% of plan members on 5 or more prescription drugs. Since most people don’t get much time with their primary care physician, and since many people have a care team consisting of multiple physicians, it’s not uncommon for patients to end up with not only duplicative and wasteful prescriptions, but also dangerous combinations that can exacerbate symptoms and lead to expensive hospital visits. Not to mention the fact that many drugs are prescribed specifically to mitigate harmful side effects caused by another prescription. 

Fortunately, when patients with complex conditions and high numbers of prescription drugs connect directly and regularly with a clinical pharmacist, we see similar benefits — clinical and financial — as those realized when a dietitian, physical therapist, or psychologist get added to an individual’s care team as with so many of the prominent point solutions today. 

With many of these solutions, it can, however be challenging to get patients to engage with their care team. One benefit of active medication management is that patients not only get clinical help navigating and adjusting their prescription drugs so that they feel better and get better, they also save money on expensive copays that add up — especially for those taking five or more medications. 

In fact, people who actively engage in medication management save $1,100 annually, with more than 90% of those savings realized by the plan sponsor.

The source of these savings is illuminating. For patients, copay assistance drives 65% of member cost savings, with in-network transfers contributing 25%, and therapeutic interchange delivering 10% of total cost savings. 

On the plan side, a whopping 55% of cost savings come from therapeutic interchange, with 40% coming from the deprescription of unnecessary meds, and 5% via transfers to in-network pharmacies. 

On top of the financial savings, including a clinical pharmacist in a patient’s broader care team provides a much-needed bolster to America’s overwhelmed primary care doctors who have neither the time nor frequency of interactions with patients to actively manage most medications. When pharmacists recommend a prescription change, 86% of doctors accept those recommendations. 

Of course, this type of active medication management at the individual level is really just an extension of what PBMs already do at the organizational level. By picking up where PBMs leave off, clinical pharmacists can help plan sponsors see cost savings and clinical outcomes through to the individual level.

Photo: megaflopp, Getty Images

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