Disparities in the U.S. health system have come into sharp focus over the past one and a half years. We knew disparities existed before Covid-19, but the pandemic has sounded an undeniable call to action. What steps will we take towards a more equitable health system?
Despite significant flaws exposed by the pandemic, the crisis also illuminated the resilience, determination, and dedication of those who work in healthcare. Providers discovered innovative ways to care for the patients who needed them. Now, we must seize that momentum. We must reimagine the future of care and solve the challenges that have hindered health equity in the past. Pharmacy benefits managers (PBMs) are in an excellent position to lead the way by embracing the precepts of value-based care.
For too long, the PBM business model has had more in common with retail entities than healthcare organizations. As “middlemen,” the conversation has historically rested squarely on price, rebates, and discounts—and that’s the problem. It’s okay if people don’t have equal access to the latest trend in clothing or cars. Healthcare, however, is fundamentally different than retail. There should be no disparities in access to pharmacy benefits.
PBMs today have a tremendous opportunity to help address health disparities by shifting current drug pricing and “cost vs. access” conversations to value-based discussions. They should consider how to provide the right drug, at the right cost, at the right time. Success should be measured in terms of clinical outcomes alongside financial outcomes and patient-centered care. PBMs can do their part to create more equitable and holistic care by:
- Shifting the emphasis from condition-oriented treatments to “whole-person” care
- Removing barriers to access through a broad network and open formulary models
Strengthening whole-person care
Health maintenance organizations (HMOs) of the 1990s had their share of difficulties, but they did get one thing right: they allowed primary care providers (PCPs) to serve as patient care quarterbacks. PCPs had visibility into the services their patients received, which meant they had a relatively complete picture of their patients’ overall health.
As HMOs went by the wayside, condition-oriented clinical programs took their place. Today it’s common for someone with Type 2 diabetes to enroll in a diabetes management program, while someone with chronic heart failure (CHF) is steered toward a CHF program. Sounds logical, right?
Here’s the problem: Condition-oriented clinical programs lack a “quarterback” with a holistic view of the patient. By narrowing their focus to one dominant condition, they often fail to deal with critical underlying social, behavioral, and physical comorbidities that significantly increase clinical and financial risk. Consider the patient with Type 2 diabetes as an example. A condition-oriented diabetes program might zero in on healthy diet tips and weight management strategies, but never identify or address the patient’s comorbid hyperlipidemia and chronic kidney disease (CKD)—each of which could drastically impact clinical and financial outcomes.
PBMs have a unique opportunity to become de facto health quarterbacks because they can provide the missing 360-degree patient view. That’s especially true if they operate under value-based, pay-for-performance models that reward proactive health management. Under such models, PBMs are no longer incentivized to increase the volume of drugs ordered. Instead, they are driven to achieve defined clinical and financial metrics.
This shift in focus makes a tremendous difference. It gives PBMs a reason to invest in technologies and workflows to proactively care for patients’ whole health—not just their dominant conditions. It employs pharmacists as active members of the patient care team— engaging PCPs and other providers. It optimizes clinically appropriate treatment plans based on patients’ unique risk profiles, as long as they are equipped with population health data and insights. By looking at the whole patient, pharmacists optimize utilization and enhance outcomes, which lowers costs as well.
Shift to open access models
Pharmacy deserts are another cause of health disparities that must be solved to achieve equity. If we look at Covid-19 vaccine administration as an example, it should be unacceptable that data shows 111 rural U.S. counties have no eligible pharmacy to administer the COVID-19 vaccine. It’s not just rural residents who suffer, though. The pandemic has also starkly revealed a lack of pharmacy access for the urban poor.
There are some aspects of the pharmacy desert challenge that we can do little about, of course. But we can control whether policies and procedures limit or open access to retail pharmacies. Why should holding the line on costs require network carve-outs and shrunken formularies?
Once again, the adoption of value-based care models can ease the path to greater equity—this time by opening up pharmacy access. The reason is quite simple: value-based models recognize that the longstanding “cost vs. access” dichotomy is flawed. It has not been proven to bend the cost curve or enhance patient care quality.
So why does the “cost vs. access” conundrum exist? What would happen if incentives promoted open access and proactive cost management rather than more prescriptions? The answer is clear: It would ensure that people get the medications they need in the manner that’s most convenient for them, with the likely downstream effect of better adherence and outcomes.
In reality, artificial cost vs. access limitations disappear when the overarching incentive is to improve clinical and financial outcomes. Every time we ensure that policies, procedures, and workflows revolve around true patient care, we add value back into the healthcare ecosystem.
Equity starts with value
A proactive approach to whole-person health is far better, and cheaper, than trying to mitigate illnesses after they’ve developed. That’s the underlying wisdom that has driven value-based care across the healthcare continuum. PBMs, too, should embrace this philosophy.
Covid-19 has revealed a huge opportunity to reduce health disparities by refocusing on delivering value, which is by no means a simple feat. Reimagining a more equitable and person-centered healthcare system requires healthcare leaders to confront the status quo. Nevertheless, it is possible.
We need to get back to caring for whole people—not just their acute diagnoses. That means identifying and accounting for comorbidities. It means adopting a more preventive attitude about care. We also need to do everything in our power to open up pharmacy access and eradicate pharmacy deserts. If we do these things, we can begin to replace existing health disparities with a more equitable health future.
Photo: PeterPencil, Getty Images