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Value-Based Pharmacy Management
Value-based management strategies can help ensure a sustainable future for the pharmaceutical and health care market and enable payors to control costs, while providing an affordable benefit to their plan members. However, certain controls and parameters — guardrails — are essential to ensuring that payors benefit from such strategies and can derive maximum value for their prescription drug spend. To be successful, value-based approaches must be tightly managed with key cost control measures in plan design, pharmacy network, and formulary, to ensure utilization of the right drug at the right time for the right patient.
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When considering whether, and what, value-based management approach will help meet the cost control goals and the needs of their member population, payors need to consider a few key elements.
Such networks can be designed around different outcomes such as improved adherence to medication therapy or compliance with test recommendations. Pharmacy reimbursement can be linked to achieving such outcomes, driving incremental value and helping payors realize their overall cost control goals.
Mandatory Use of Specialty Pharmacy
To help mitigate the risk of non-adherence, value-based approaches often use a specified level of adherence as a pre-qualifier for the measurement of other treatment outcomes such as better A1C control for diabetes, or prevention of adverse events. To realize these outcomes goals, payors must align with a specialty pharmacy network, such as CVS Specialty, which has trained clinicians who proactively offer patients support for complex conditions, manage comorbidities, counsel about side effects, and can intervene when appropriate to help patients stay on therapy or complete their treatment. Patients with access to CVS Specialty and care management saw an average of 5 percentage point increase in medication possession ratio compared to those using a retail pharmacy only.
Standard Utilization Management Criteria
Additional formulary measures such as a preventive drug list and point-of-sale rebates can help plans that choose a high deductible design support their value-based management goals by mitigating the out-of-pocket cost impact on members so that more of them stay on therapy.
Better Outcomes at Lowest Net Cost
Managed networks can help reduce costs as well as help improve clinical outcomes by supporting health and wellness initiatives.
A comprehensive formulary strategy is foundational to mitigating the impact of escalating drug prices, and the introduction of new high-cost therapies.
Adherence results may vary based upon a variety of factors such as plan design, demographics and programs adopted by the plan. Client-specific modeling available upon request.