Michael Kolodij PharmD, manager of pharmacy programs, Blue Cross & Blue Shield of Rhode Island                             

What is medical/pharmacy integration, and why does it matter to your business? If you are an employer providing health benefits to your employees, integration is one of the easiest decisions you can make to both reduce healthcare costs, and more importantly, provide your employees with the most comprehensive, holistic healthcare possible.

The integration of these benefits creates a collaborative network among patients, their providers and the health insurance plan, resulting in higher-quality care and a healthier workforce. With a connected and coordinated system, information and data flows more seamlessly across the entire group - from primary care providers, to specialists, to dental and vision providers, and pharmacies - which results in a comprehensive understanding of employees’ overall health. This real-world insight allows health issues to be identified and treated more quickly and accurately, and for gaps in care to be resolved.

Employers can be overwhelmed with information about the advantages of “carving out,” or purchasing pharmacy benefits separately from core medical benefits. Pricing in the pharmacy benefit manager (PBM) industry can be complex, even confusing, and so it becomes challenging to determine quoted prices versus the true cost of pharmacy benefits. The reality of carving out is not always in line with an employer’s strategic healthcare objectives.

Integration can lower medical costs

Blue Cross & Blue Shield of Rhode Island (BCBSRI) data from 2017 shows that companies with integrated pharmacy and medical benefits experienced lower medical claims expense for several chronic conditions. Specific examples of reductions in the cost per employee per month include:

• Hypertension – 10%
• Diabetes – 18%
• Substance use disorder – 19%

Integration leads to better outcomes and quality of care

Integrating medical and pharmacy makes healthcare benefits administration easier, and more cost-effective, for most organizations. They only have to work with one vendor, which streamlines responsibilities and improves employee access to care. This can often be in stark contrast to the divide that carving out creates between medical benefits and PBMs, which can leave patients unable to access medications. Additionally, in an integrated plan, employees typically have one ID card and a single online experience to access all of their health benefits, as well as a single customer service team that can answer both pharmacy and medical benefit questions.

Pharmacy integration also fosters a coordinated approach to managing employee health, with a consistent strategy for coordination of care management with doctors, hospitals and pharmacies. Because it involves a more comprehensive approach to health and well-being, integration can be an effective way to enhance the quality of care. It can:

• Provide a greater opportunity for effective interventions by identifying over- and underutilization of medications based on medical data
• Help identify and close gaps in care more completely compared to carve-out PBMs

BCBSRI developed the Patient-Centered Pharmacy Program (PCPP) as an interdisciplinary team approach to health care. It integrates pharmacists with providers and the on-site care team within medical practices working in close collaboration. This PCPP model translates to more effective care strategies for individual patients that address medication-related issues and overall health goals. Since 2014 our PCPP has created $37.5 million in total healthcare savings.

While much of the analysis of integration is focused on cost efficiencies, the bigger story is how that integration will transform models of care. Our studies show that members with access to a patient-centered pharmacist have:

• 12% lower pharmacy costs
• 9% fewer emergency department visits
• 6% fewer inpatient hospital stays

The value of pharmacy and medical integration is the ability to have a comprehensive understanding of an individual’s health journey. At BCBSRI the view of the patient journey created by integration is 360 degrees – care gaps are addressed, cost often decreases and administrative efficiencies are realized. This can also result in significantly lower costs, making integration the smart, and in my opinion, the only choice for employers.

For more information about pharmacy costs and integration, visit http://bcbsri.com/b2blue/pharmacy.