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Pharmacy integration helped BCBS of Rhode Island lower costs, improve care


Guest post by Beth Herbert-Silvia, managing director/AVP of pharmacy at Blue Cross & Blue Shield of Rhode Island

Although pharmaceutical costs are a key driver of healthcare costs, it's frequently assumed that's because of the high price of drugs, specialized treatments for complex diseases and unnecessary prescriptions. Yet studies have shown that medication non-adherence adds up to $290 billion per year to healthcare costs in the U.S.

One real-world solution is to more fully integrate pharmacists into the care team.

Traditionally, a pharmacist's role has occupied its own separate silo. They frequently receive and fill prescriptions off-site, and patients often decline their friendly offer to provide information or answer questions. But the physical presence of a pharmacist in primary care offices can be a game-changer. They can provide one-on-one medication consultation and support to both physicians and patients.

In a pilot program called the Patient Centered Pharmacist Program (PCPP), on-site pharmacists were placed in six patient-centered medical home (PCMH) practices across Rhode Island, reaching more than 30,000 patients. Initial patients are Blue Cross & Blue Shield of Rhode Island Medicare Advantage members of any age and members age 60 and older with other selected plans. The demographics reflect patients who are likely to have complex medication needs and stand to benefit from a program like the PCPP.

Pharmacists who are on-site with a direct impact on the team-based approach to healthcare can work with patients and their caregivers to ensure patients are taking the most appropriate medication for their needs, using proper administration techniques and, when appropriate, filling lower cost generics to reduce patient expenses without compromising quality of care. Although use of generics is widely accepted across the United States, the avoidable cost opportunity from underutilization of generics is estimated at about $12 billion, according to the IMS Institute for Healthcare Informatics.

Studies have shown consistently that 20 percent to 30 percent of prescriptions remain unfilled and that approximately 50 percent of medications for chronic diseases are not being taken as prescribed.

Beyond the obvious financial costs associated with prescribed but unused pharmaceuticals, the cost to individual and population health is significant. Non-adherence to drug regimens is estimated to cause approximately 125,000 deaths annually and at least 10 percent of hospitalizations, according to a study from the Annals of Internal Medicine.

With access to a pharmacist as part of their medical visit, patients can benefit as their doctors and nurse practitioners work directly with the pharmacist to make medication regimens more manageable, which means it is easier for patients to stick with them. They can also do more to make sure that patients avoid drug interactions and even help minimize unnecessary side effects.

The pharmacists working in the six PCMH practices had several distinct roles:

  • Medication therapy management: Ensure that the optimal medication is prescribed to address condition.
  • Medication reconciliation and transitions in care: Limit cases where prescriptions interact or physicians are unaware of the entire pharmaceutical picture for their patients.
  • Increase in generic dispensing rate: Improve patient access to medications by reducing their out-of-pocket costs.
  • Total care model: Consider other aspects of medical care (such as diagnostic screenings) that might change or impact existing medication regimens.

The pilot program resulted in unprecedented engagement rates for complex care patients, with significant in-person counseling, modifications to prescription regimens and collaboration with the PCMH team. With almost 22,000 Medicare members eligible to participate in the PCPP, more than 60 percent engaged offered services, totalling approximately 400 comprehensive medication reviews and more than 750 targeted medication reviews.  

Savings associated with the PCPP totaled more than $1 million, with Medicare patients alone saving more than $800,000. More importantly, physicians and patients alike have come to recognize the important role pharmacists play as part of the overall care team.