PBM and Community Pharmacy Partnerships Can Improve Medicaid Outcomes
Value-based partnerships between pharmacy benefit managers (PBMs) and independent community pharmacies can improve outcomes for health plan members with complex or chronic conditions. Early results from Elevance Health’s partnership with a performance-based network of community pharmacies showed improvements in use of medications and healthcare services among one state's Medicaid members.
Pharmacists have been shown to positively affect chronic disease outcomes through medication therapy management and other counseling services, and are increasingly being rewarded for their expanded role as clinical providers in value-based contract arrangements with health plan-integrated PBMs. Further, individuals may visit community pharmacies twice as often as other healthcare providers, offering more frequent opportunities for engagement.
This paper presents findings from a high-touch program available to help Medicaid members manage asthma, chronic obstructive pulmonary disease, mental health conditions, and opioid use disorders. Participating members had reductions in inpatient hospital and emergency department visits, among other healthcare services, and improved adherence to medications prescribed for their conditions.
Related Public Policy Research
There is a growing understanding of the clinical roles that pharmacies and pharmacists can play, beyond medication dispensing and adherence, such as medication adjustment, vaccination, and outcomes monitoring. Value-based payment (VBP) in pharmacy has the potential to recognize the contributions pharmacies and pharmacists can offer to improve patient outcomes and reduce costs.
Understanding the Role of Pharmacy Benefit Managers in Healthcare
PBMs are companies that administer the prescription drug benefit for health plans and employers. PBMs add value in three primary ways: improving health outcomes using evidence-based clinical programs, effectively managing pharmacy networks, and using financial management strategies to reduce prescription drug spending and costs.
Approaches to the Medicaid Prescription Drug Benefit
States that employ Medicaid managed care organizations (MCOs) to pay for prescription drugs outperform states that rely on the fee-for-service (FFS) setting to control drug costs.
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