Health IT will drive closer alignment for all stakeholders

Calabrese Across the country, healthcare leaders are working to re-engineer our healthcare system and drive much-needed improvements in access, coordination, quality and cost-effectiveness. Integration and interoperability are critical to this effort. As such, payers and providers are embracing new healthcare entities such as patient-centered medical homes and accountable care organizations as well as new forms of quality-based reimbursement as key vehicles to deliver these objectives. This transformation is encouraging and presents the pharmacy benefit management (PBM) industry an ideal opportunity to transform itself into a critical catalyst in support of these efforts. 

In line with this opportunity, “pharmacosynchrony” is a new concept that is rapidly attracting interest across the healthcare community. Pharmacosynchrony leverages innovative PBM clinical, analytic and technological solutions to drive enhanced care coordination and a higher-quality, more patient-centric approach to care.  By unleashing the underused power of pharmacy data, advanced information technology (IT) systems and comprehensive clinical resources, this congruence of strategies creates a closer alignment and partnership  between PBMs and health plans, employers, provider systems and patients. The targeted result: improved care delivery, better health outcomes and lower costs.

Data and analytics 

It is clear that today’s payer world is far less interested in the traditional PBM business model and much more demanding of new and elevated levels of clinical monitoring and intervention, information exchange and analytics, and cost savings vehicles that yield a much more robust and holistic level of support and service, often extending beyond the pharmacy benefit. PBMs are being driven to develop new means of connectivity with the provider and patient communities to facilitate improved education and engagement in evidence-based standards of care. 

Sophisticated data warehousing and analytics capabilities will be required by PBMs to assist health plan clients and providers with care coordination. This will undoubtedly include the application of validated risk adjustment methodology and patient segmentation to help providers better identify patients at higher risk of negative clinical outcomes. This will also enable PBMs to better tailor communication strategies and clinical programs in ways that are accepted by the patient community and most likely to deliver desired results. A PBM’s ability to integrate and effectively analyze both medical and pharmacy claims activity in near-real-time fashion will further enhance these activities, while simultaneously assisting with improvement in key quality metrics, such as pharmacy-based HEDIS and Medicare STAR measures.

To fill the void in the new delivery systems, PBMs must capitalize on new communication vehicles including the Internet, mobile technology and EHRs. Each will improve timely access to key data and information, such as patient-specific clinical alerts regarding adherence, gaps in care and drug utilization review (DUR) issues, permitting more proactive intervention. Improved connectivity and coordination of care can also help to prevent negative clinical complications and their associated higher expenditures. 

Because these objectives are complex, achieving success will not be a simple undertaking. Only through such a foundational shift will the PBM industry attain the close alliance with its industry partners that will inevitably help drive the nation’s healthcare to higher levels of quality and cost-efficiency. In doing so, this concept of pharmacosynchrony offers the industry an opportunity to earn a higher standing within the healthcare system, and society at large, as a pivotal resource in bringing about much-needed change.

David Calabrese, RPh, MHP, is vice president and chief pharmacy officer of Catamaran. He also is an editorial advisor for MHE.