As health systems become more integrated, health plan pharmacy directors are finding themselves in a more collaborative role, taking on new responsibilities that break them out of the mold of the traditional pharmacist
As health systems become more integrated, health plan pharmacy directors are finding themselves in a more collaborative role, taking on new responsibilities that break them out of the mold of the traditional pharmacist.
The Institute of Medicine (IOM) outlined five core competencies for healthcare professionals critical to providing high-quality, safe care. IOM included pharmacists in its description.
The framework has helped set the stage for the next generation of pharmacists as leaders in the industry. Pharmacy directors agree that two of the most critical details facing them today are integrating the medical and pharmacy sides of the healthcare benefit and managing the high cost of specialty drugs.
As a pharmacy consultant, Ruth Opdyke, president of TPG Healthcare Consulting, observes the changes for pharmacy directors in the trenches. Much time and effort is dedicated to managing drugs across the total spectrum of care, including the utilization of costly specialty drugs.
As pharmacy directors take on more responsibility for managing drug spend on the medical side of a plan, they are also concerned with quality and outcomes related to pharmacy disciplines, Opdyke says. Metrics associated with HEDIS measures and Medicare star ratings must be a top priority.
“It is no longer just a matter of squeezing down costs by establishing tight contracts with manufacturers and PBMs but also how to find the most appropriate drugs based on evidence-based medicine,” Opdyke says.
Besides the high-cost of new drugs in the marketplace, she says pharmacy directors are still plagued by age-old problems-making sure that drugs are used appropriately for best outcomes and that patients are adhering to their medication regimens. For example, one ongoing issue is the appropriate use of a controller medication versus a rescue medication for asthma patients, she says.
In many health plans, pharmacy directors and their teams are responsible for making recommendations to a Pharmacy and Therapeutics (P&T) committee and applying the decisions to real-world practice in their plans. That proposition is becoming more complex with companion diagnostics and genetic testing, for example. Evaluating drugs and their optimal use in the real world will continue to be an evolving challenge in the future.
“There are a host of medications in many different environments, including doctors’ offices, home healthcare and hospitals, that need to be managed by a pharmacy director,” says Peggy Johnson, chief pharmacy officer, Horizon Blue Cross Blue Shield of New Jersey, in Newark.
Saira Jan, director of clinical programs at Horizon, says she is accepting more responsibility for strategy and product development as drug costs accelerate and as health reform leaves a trail of changes. She is more closely attuned to drug utilization guidelines and outcomes that necessitate more interfacing with other departments in the health plan, such as care and case management.
“Product development is now more commercially driven, with an eye on employers and individuals,” says Jan, who also serves as co-chair of Horizon’s P&T committee responsible for formulary, benefit design, drug utilization and developing programs with clinical benefits.
She says that the committee is also looking at its role in a different light with more focus on data, health information technology, outcomes management and drug trending.
Johnson says that paying close attention to data can help identify drug side effects and dangerous interactions among medications. “How a drug fits into an entire therapy protocol is being considered holistically, enhancing the position of the P&T committee,” she says.
Pharmacy directors will see an enhanced role with the development of both accountable care organizations and patient-centered medical homes.
“These integrated models allow pharmacists to collaborate with physicians to ensure proper drug utilization and improve quality,” Jan says.
The two models provide an opportunity for pharmacy directors to serve as consultants and to lay the groundwork for population management, says Johnson.
Although Horizon uses the services of a pharmacy benefits manager (PBM) to integrate utilization rules with claims adjudication, develop a national pharmacy network and provide benchmarking data, Jan says the buck stops with the plan, which makes ultimate decisions.
Eric Cannon, chief of pharmacy for SelectHealth in Salt Lake City, says that the single biggest challenge he faces is the impact of more specialty drugs and infusibles entering the marketplace, making it necessary to manage drugs under both the pharmacy and medical benefits. However, the arrival of oral oncology drugs that are replacing some injectables, is raising costs on the pharmacy side as utilization increases.
As the head of pharmacy at his health plan, Cannon is responsible for drug costs and budgeting under both benefits, wherever the drugs are being paid, he says, as well as for appropriate utilization. For example, he explains that the implications of replacing one drug for another or adding to an existing therapy must be examined within the bigger financial picture.
The director of pharmacy, who is on Cannon’s staff, serves on the plan’s P&T committee, while clinical pharmacists on his team review the evidence for different therapies to present to the committee.
The key to success and improving outcomes is communication, Cannon says, referring especially to pharmacists and physicians. For example, a collaborative approach was particularly critical in determining which of four dipeptidyl peptidase (DPP)-4 inhibitors for diabetes would be included on formulary based on outcomes in practice. Horizon decided to include two of four available options.
Appropriate utilization of drugs is a major concern of Cannon and his team, who rely on traditional tools such as prior authorization and step therapy, but also on clinical editing in the claims system.
New, costly drugs in the marketplace that may only have limited benefits also draw attention, catching pharmacy leaders in a difficult cost-benefit analysis.
“How do you say ‘no’ to a patient who wants to try an experimental, costly drug that lacks sufficient evidence and shows little impact on overall survival?” Cannon asks.
Steve Ritter, director of pharmacy, Blue Cross and Blue Shield of Minnesota, says that while the cost of pharmacy has always been important, it has become more critical with the advent of specialty pharmacy. Directors must take a holistic approach to managing the drug benefit. “We have broadened our approach and are looking at anything that may affect cost,” he says.
Ritter advocates for members’ pharmacy benefits and serves as an educator and forecaster-studying what is coming down the pipeline next.
BCBS of Minnesota uses Prime Therapeutics, Eagan, Minn., as its PBM, providing information to help the plan make decisions, says Dale Carlson, vice president, clinical programs for the PBM. “We don’t just do cost modeling, but look at the total impact of drugs on all care,” he says.
As director of pharmacy partnerships and product strategy at Highmark Inc. in Pittsburgh, Sarah Marche understands the business side of pharmacy. She oversees two teams, one that develops strategy with manufacturers and vendors, while the other focuses on product design strategy, including formulary management.
Her primary concerns are paying for drugs appropriately and advocating for an integrated budget between pharmacy and medical. Marche is also in charge of contracting with manufacturers for drug pricing with a variety of contracts, establishing appropriate drug rebates and managing drug spend.
Marche says that it is critical to be comfortable with change in order to react quickly to the industry, such as adapting product design to stay ahead of the curve and to drive appropriate healthcare. For example, Highmark previously had only one pharmacy network for members in its commercial plans, but now has three, which range in size and cost savings for its members. However, the larger the network, the less cost savings.