Ending Waste, Optimizing Outcomes

The September edition of Spotlight on Benefits focused on the two primary sources of drug waste—channel waste and drug-mix waste—these along with patient non-adherence to drug therapy, account for the 33% of drug spend that is wasted annually.

When a plan member uses pharmacy services that are more expensive, or takes a medication that costs more but offers no clinical advantage, waste occurs. When a patient does not take their medication as prescribed, their health outcome is compromised. All of these poor decisions unnecessarily increase costs for both plan members and plan sponsors and lead to suboptimal health outcomes for patients.

Express Scripts Canada’s research shows that most plan members want what plan sponsors want—healthier outcomes and lower costs. However, the large amount of waste in employer sponsored drug plans proves that there is a huge gap between what plan members want and what they do. Understanding this gap between intention and behaviour—and how to close it—is the key to helping plan members make better decisions.

To understand this gap, you first need to appreciate that it isn’t easy for plan members to choose wisely. They seldom understand drug therapy choices and almost never understand drug pricing.  In addition, plan members are guided by healthcare providers who often lack the time, information and motivation needed to help them make good decisions based on their benefits plan. To complicate matters, with people being wired for inattention and inertia, it is difficult to capture their attention long enough—or at the right time—to change behaviour, especially when it comes to drug benefits.

Traditional solutions control costs; however, they are ineffective at changing plan member decisions. Plan sponsors need a new strategy—one that will supplement traditional adjudication tools with strategies designed to help plan members make informed and cost-conscious decisions.

Pharmacy benefit management (PBM) services are one option available to enable plan sponsors to better manage the cost of their prescription drug benefits while also providing plan members with an enhanced prescription drug service. While PBM services are more fully developed in the U.S., they are making their way into Canada.

For example, Express Scripts Canada’s PBM service uses tools that apply behavioural sciences to healthcare decision-making in order to influence plan member behaviour. Plan members, with the support of their physician, are encouraged to interact with a team of professionals to learn about their maintenance medication alternatives, thus enabling them to make more informed choices. The resulting decisions will offer the best possible health outcome while also reducing costs for both the plan member and plan sponsor. Plan sponsors can add this service as an enhancement to an existing drug benefits plan without changing insurance carriers or adjudicators.

Therapy optimization is another important component of enhanced PBM services. Doctors often prescribe the higher-cost brand medication, which can be costly to both the patient and the plan sponsor. PBM services can help by developing and administering a therapy optimization program, whereby a licensed pharmacist works with the patient and doctor to help them consider replacing existing medications with clinically and/or therapeutically equivalent lower-cost alternatives. This program is particularly effective when used in conjunction with behavioural science tools.

With the coming wave of high-cost specialty drugs, a PBM service is one solution to enable plan members to make informed, cost-conscious decisions, while helping plan sponsors preserve their drug benefits.

If you have any questions or would like to discuss Express Scripts Canada’s 2013 Drug Trend Report in more detail, please contact your Benefits Consultant.