Prescription Care Management

PCM saves 10-15% of total drug spend by utilizing therapeutic alternatives………….

By Garret D’Antoni

It is not news to anyone that prescription drug costs are skyrocketing at an alarming rate.  The Turing Pharmaceutical fiasco of 2015 was evidence enough that pharmaceutical companies think they are above reproach. However, big pharma, with its free meals and discount programs, is not solely to blame for outrageous drug prices. The government isn’t helping, either; after reviewing thousands of studies, Harvard Medical School found that the lack of regulations for big pharma, government monopolies, and FDA backlog are also to blame for rising prices.

What are benefit managers, or patients, for that matter, supposed to do? Cut already slim formularies? Fork out millions of dollars to cover one or two specialty drug prescriptions? Join the 4 million Americans who simply leave their drugs at the pharmacy counter because the cost is too high?

Stop. Don’t do any of those things.

Start fighting high drug prices by switching the most expensive prescriptions to lower-cost alternatives at the source: the physician. Physicians are often misinformed as to how much the medication they are prescribing costs. Their prescribing guides don’t provide cost information, so they select drugs based on information given them from pharmaceutical reps. If they knew the out-of-pocket cost their patient and patient’s plan would be paying for prescriptions, many physicians would consider lower-cost alternatives.

There have been a few attempts to create programs to address this issue but, as always, we need to follow the money. Pharmaceutical manufacturers have little incentive to make changes, while consultants and brokers walk a difficult line of member disruption. If they make formulary changes that could lead to significant savings, they may lose revenue from rebates. One proven solution, however, comes from Prescription Care Management (PCM), a company with a unique approach.

“The PCM Program is easy on both the benefits team and the employees,” says Garret D’Antoni, CFO. “We work with the employee’s doctor to drive savings. The physician is the ultimate decision-maker; we help them understand that there are cost savings opportunities. These are savings that the employer and the employee see immediately.”

By identifying low cost alternatives to high cost drugs, the PCM Program consistently saves employee money at the pharmacy counter and group money on total health care spend.

D’Antoni explains, “On average, PCM saves 10-15% of total drug spend by utilizing therapeutic alternatives. Since implementation in 2015, PCM has identified $1.8M in savings for a group of 23,000 employees. PCM finds these savings by focusing on the source of most high-cost prescriptions: the physician.”

Focusing on the physician is key, because knowing the price differences of therapeutic alternatives is not part of physician training. If a medication fits the diagnosis the physician will prescribe it, regardless of price. However, price differences between drugs – brand to brand, brand to generic, and generic to generic – are significant, and the introduction of 4- or 5-tier formularies are shifting the cost of more expensive medications to the patient.

Additionally, many physicians are overworked. Increased patient volume, a result of the focus on providing healthcare for the masses, has physicians working longer hours, sometimes to the detriment of their patients. On average, an appointment with a primary care provider will only last 15 minutes; this is hardly enough time for the physician to take an accurate medical history, assess the problem, and research viable treatment options. Unfortunately, physicians have very little control over the cost of routine visits, and the health care system works off pay structures that allow only a short amount of time for each patient. This trend leads to scripts being written for whatever is most common or typically covered by insurance, regardless of cost to the patient or plan.

The cost of this type of visit wreaks financial havoc on patients. In 2015, the average cost of a primary care visit for someone without insurance averaged $200, or one tenth of their monthly income. With insurance, this number can be significantly lower, around $25 per visit, but may be subject to deductible and out-of-pocket costs. On top of paying for just a few minutes of a rushed physician’s time, many patients leave appointments with scripts for prescriptions exceeding $1,000 without an explanation from their doctor about why that particular drug was chosen. This is especially true for patients with chronic illnesses like diabetes and arthritis.

Both physicians and patients feel the strain of constantly rising prescription drug costs. Several states are attempting to rein in spending, but without an immediate cost savings solution, individuals and plans will continue to suffer. Misinformation, the office visit time crunch, and a volatile prescription market are all leading to a problem so daunting that a solution may seem impossible.

“PCM empowers physicians to look beyond high-cost medications towards lower-cost alternatives. It is an innovative, proven solution to rising drug costs,” D’Antoni says. “Physicians can choose to prescribe safe, effective drugs that don’t leave individuals and health plans in financial crisis.”

With a program like PCM working with members and groups to identify these lower-cost switches, physicians are the key to immediate, measurable, and long-term savings.