Eight Trends Expected to Shape Managed Care Pharmacy in 2020

MHE Publication, MHE December 2019, Volume 29, Issue 12

New administrative technology, treatment enhancements, and more.

The year 2020 will see both new opportunities and continued challenges in managed care pharmacy. Technologies will play a major role in enhancing administrative processes while treatments will continue to become more advanced, to name a few.

Here’s a look at eight trends that experts expect will shape the industry next year:

  • Continued shift to value-based care. Thomas R. Bizzaro, RPh, vice president, Health Policy and Industry Relations, FDB (First Databank, Inc.), a San Francisco-based company focused on providing trusted medical knowledge, expects to see an ongoing move in managed care pharmacy from fee for service to value-based care in 2020, with an expanded focus on quality of care and outcomes. “There’s no longer a controversy about whether the industry is moving away from fee for service-the question now is how fast the move to value-based care is going to happen,” he says.

    In this emerging environment, Bizzaro says payers and providers will work even more closely together, with shared responsibility for outcomes and shared risk and rewards tied to the cost of care. Meanwhile, CMS and private insurers will continue to expand these payment models to areas that traditionally weren’t covered to improve outcomes. There will be a growing focus on educating members to improve their understanding of their medication therapy (i.e., why they’re taking a drug, when they need to take it, and possible side effects). “This knowledge will ultimately improve adherence,” he says.

    Related: Opinion: Bending the Pharmacy Cost Curve with Population Health Management

  • Increased integration of medical and pharmacy benefits. Historically, medical, and pharmacy benefits have been siloed. When employers and other organizations design benefit plans, they typically use one company for medical benefits and a different one for pharmacy benefits. Because the companies are separate entities, they don’t share data or information. Therefore, there’s a disconnect.

    “As a result, plan sponsors are challenged to ensure that members receive coordinated care and understand the true cost of care,” says Jerry Buller, DPh, MMHC, chief pharmacy officer at Trellis Rx, a specialty pharmacy located in Atlanta that partners with health systems to enhance patient experiences. “These issues are particularly relevant for patients with chronic and complex conditions, who often require high-cost specialty medications. A plan sponsor and medical team may miss important opportunities to comprehensively manage a patient’s care.”
    Moving into 2020 and beyond, Buller believes plan sponsors will begin demanding solutions that address these siloes. Today, UnitedHealthcare’s Optum has programs that provide insight into both medical and pharmacy benefits. Other companies are attempting to replicate this via mergers and acquisitions. Finally, more integrated delivery networks are now offering comprehensive health plans as a solution to these challenges.

  • Drug prices will continue challenging patients, payers, and providers. In particular, Ryan Foster, PharmD, MBA, senior director, pharmacy, Spectrum Health, a not-for-profit, integrated health system in Grand Rapids, Michigan, expects the specialty pharmaceutical segment to keep growing, which will require novel approaches to ensure patients are able to access needed medications. Annual growth in per capita spending in this market has averaged 14% since 2013.

    “Many specialty drugs show great promise but have limited data because of the relatively small populations in which the medications are indicated,” Foster says. “The healthcare system simply cannot afford inappropriate use of these types of medications.”

    System design makes it exceedingly difficult for providers to select the lowest cost therapeutic option for their patients. “Tools to increase transparency and improve decision making (i.e., real-time prescription benefits, electronic prior authorization tools), are not well-developed and hinder providers from selecting the most cost-effective medication,” Foster says.

    Along these lines, as tension and attention build over drug costs, Karthik Ganesh, president, EmpiRx Health, a risk-bearing pharmacy benefit manager located in Montvale, New Jersey, expects increased accountability across the spectrum to bend the prescription cost curve. This includes the deployment of empirical data to empower pharmacists to disrupt ineffective treatment regimens in partnership with the prescriber; revising prescription protocols to deliver the most clinically-appropriate treatments at the lowest cost the first time; and a more disciplined approach to population risk management in order to balance drug mix in a way that rewards reduction in total costs while also improving clinical outcomes.

  • Medication systems will gain connectivity. Despite substantial investments in electronic health record systems, computerized physician order entry, barcode medication administration, smart infusion pumps, and other technologies, process improvements have been small. “These technologies often work in isolation and don’t communicate with each other to form a connected system,” says Tom Utech, vice president of solution management at BD.

    Hospitals are using disparate systems from too many vendors, which may contribute to the problem. According to the Healthcare Information and Management Systems Society (HIMSS)’s Medication Management Technology Index, on average, hospitals use 5.8 medication management solutions from 4.5 different vendors.

    Faced with these disparate systems, nurses and pharmacy staff often develop time-consuming manual workarounds, which can impair workflows. “In particular, these workarounds can delay patient care, undermine standardization, and potentially jeopardize patient safety,” Utech says. “To optimize technologies, these solutions must be connected.”

    Fortunately, hospitals are beginning to recognize the problem. According to a HIMSS analytics study of 153 healthcare professionals, 71% of respondents see value in moving to a single medication management vendor.

  • Precision medicine will mature. In conjunction with this, the pace of discovery and implementation of targeted therapies will accelerate. “While oncology has experienced the most significant shift in practice because of personalized therapies, we should expect to see a shift in prescribing patterns for chronic disease,” Foster says. “In the past, medication selection and dosing were based on broad, population-based studies.”

    Soon, rather than starting a medication at a dose based on population averages, providers will have the ability to select a medication and dose based on patient-specific genomic factors. “This should improve patient outcomes and medication adherence rates,” he says.

    The promise of precision medicine will force health plans and health systems alike to rethink formulary management strategies. “Although additional research will be needed in order to determine which genomic variations translate to meaningful outcomes, developments in this space are promising,” Foster says.

  • Ongoing emphasis on social determinants of health (SDoH). SDoH, which the CDC defines as “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes,” will continue to move to the forefront as a major issue in managed care pharmacy.

    “SDoH have been obvious to healthcare providers for many years, but the concept hasn’t been a focal point in the total care of the patient until more recently,” Bizzaro says. “There’s a growing recognition that not only do you need to treat physiology for disease management and prevention, but you also need to identify whether members need help with social care that can affect their well-being and clinical outcomes-including those related to pharmacotherapy.”

  • When it comes to managed care pharmacy, health plans that are investing in addressing SDoH will likely see a positive impact in areas such as medication adherence, Bizzaro maintains. For example, getting members to medical appointments is important, so increasingly, health plans and other organizations are paying for ride share services when members have transportation challenges.

    “This type of intervention means members see their providers for regularly scheduled visits, ensuring they obtain needed prescriptions,” Bizzaro says. “Their physicians are also able to monitor drug therapy, to ensure it’s effective and that members aren’t encountering issues with adherence or side effects. By viewing members and their situations holistically, medication therapy is more effective and clinical outcomes improve.”

  • Pharmacists emerge as primary care providers. More pharmacists are functioning as primary care providers, whether they are giving vaccinations at retail pharmacies or hospitals, are certified in diabetes care, or in some states, are empowered to prescribe and order laboratory tests. “In 2020, we can expect to see an expansion of pharmacists and other non-physician healthcare professionals providing this type of care,” Bizzaro says. “This approach allows pharmacists and physicians to practice at the top of their licenses; doctors can concentrate on sicker patients.”

    Orsula Knowlton, PharmD, MBA, co-founder and president, Tabula Rasa HealthCare in Moorestown, New Jersey, which provides medication risk mitigation technology, also foresees pharmacists taking on more primary care provider responsibilities, by playing a larger role in advising care, managing treatment, and taking responsibility to prevent adverse drug events, the third leading cause of death.

    “Traditionally, pharmacists and physicians have worked separately from one another. However, as a new model of patient care emerges, more hospitals and health systems will integrate pharmacists alongside physicians and nurses before prescribing decisions are made,” Knowlton says.

    There are multiple reasons for this change in the care team structure. First, while multiple players can be involved in decision making for a patient, none except the pharmacist have the unique education required to holistically assess medication regimens for effectiveness and safety. “Together, pharmacists and physicians can make impactful interventions that can lead to reduced hospitalizations and unnecessary healthcare costs associated with medication mismanagement,” Knowlton says. In addition, collaborative practice agreements are becoming more common, which is a proven model in the Veterans Health Administration clinical pharmacy program.
    Second, new pharmacy technologies seek to improve workflows, drive adherence, and identify medication safety and risk, which will demand improved dialogue between pharmacies and prescribers. “By leveraging the insights of pharmacy technologies, physicians will have the tools and information to better understand when to refer patients for pharmacist-driven clinical consultation,” Knowlton says.

    Finally, patients want a pharmacist on their care team. “They want to engage in dialogue with their pharmacist and discuss their medication profiles and safety in totality,” Knowlton says. “This could significantly reduce medication mismanagement and the risk of adverse drug events.”

    As this trend continues, Bizzaro expects to see more data and information sharing not only between health plans, pharmacy benefit managers, and providers, but also among retail pharmacies. “Currently, most retail pharmacies don’t have access to the breadth of patient information that they need to become a true partner to care for patients,” he says. “When interoperability finally becomes a reality, the future will need to include pharmacies having access to all of the information in a patient’s electronic health record. This team approach to care will ultimately lower costs and improve outcomes from a managed care pharmacy perspective.”

  • Consumers will become more cautious about prescribed medications. In the wake of the opioid epidemic, consumers are more aware of the dangers that come with taking prescription pain medications. Knowlton expects consumers to start taking responsible measures to inquire about their prescriptions, by ensuring that they are necessary and confirming that their combination of medications doesn’t have the potential for a harmful drug interaction.

    “Now, more than ever, patients have access to their medical information,” Knowlton says. “Having this information at their fingertips gives patients incentives to be their own healthcare champion, and to inquire and analyze their own medication regimen or healthcare processes.”

    Furthermore, new technologies have helped pharmacists and physicians become more equipped to share medical information with patients in a consumer-friendly manner.

    Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.