Managed Care Pharmacists and the Medical Home: The Disease Management Care Blog Examines the Prospects for Collaboration

The Disease Management Care Blog recently had the pleasure of lecturing at the annual meeting of the Academy of Managed Care Pharmacy (AMCP). As readers may imagine, this professional organization provides advocacy, outreach and education services for persons – mostly pharmacists – involved in the pharmacy plans for health insurers. The DMCB provided an AMCP educational service by offering up a session on the merits of the chronic care model and the medical home.

While most of the 80 or so pharmacists in the room knew all about disease management, few had heard of the ‘chronic care model’ or the ‘medical home.’ In its commentary, the DMCB noted that managed care pharmacists can play an important role in helping enrollees/patients be more knowledgeable participants in their own treatment plans. A post-lecture survey indicated most of the attendees agreed the concepts of the chronic care model had merit. Thanks to the DMCB, that’s 80 more health professionals who know about the medical home.

The DMCB isn’t optimistic this will make much of a difference, however. That’s because it knows that the pharmaceutical insurance plans are typically ‘shielded’ from the standard health insurance policies that they are paired with; they are sold as a ‘rider’ with their own benefit designs, underwriting, cost structure and premiums. For an example of how this works, see here.

As a result, most of the business-as-usual pharmacy leaders that were in the room have little economic incentive to coordinate their pharmacy insurance products with all that other ‘medical stuff’ going on back home. In fact, under most circumstances, they have an incentive to ‘transfer’ their pharmacy costs to the standard insurance plan. If this sounds like health care silos at their worst, you’re right.

For example, certain injectable medicines can be administered in a physician’s office (making them eligible to be covered as a medically necessary service) or at home (making them resemble any other drug that persons need to take on their own). Given a choice, the likelihood that any pharmacist would welcome these drugs' cost into the budget is inversely proportional to their price. Yet, it is the precisely the conditions treated by the high cost injectables (such as cancer or connective tissue disorders) that may benefit from close coordination with the involvement of knowledgeable pharmacists in care management services. The pharmacists’ response? Why take on the expense of taking on any of these services when that additional cost will make their insurance product less competitive and less profitable? In fact, a really good education program could attract chronically patients, further stressing the budget.

If this reminds you of the tension between physicians and managed care insurers, you’re right. Primary care physicians have also pointed out that they’re vulnerable to taking on the cost of patient education and empowerment while the financial benefit goes to the insurance company.

And that’s not all. The DMCB has generally found that the really smart pharmacists that rise to the top of their organizations do so because they understand pharmacology, pharmacoeconomics and budgeting. These are brainy hardnosed businessmen and women who have less professional affinity for the squishy business of patient education and empowerment.

The DMCB predicts as awareness of the medical home grows, managed care pharmacists will support it if they believe it can reduce their costs. If (and that is a big if) they believe it reduces their drug spend, their support will consist of:

1) agreeing that the medical home should be covered by the standard insurance benefit, since better control of disease may reduce drug consumption, and/or

2) conducting outreach activities to primary care sites that function as medical homes.

Otherwise, the DMCB thinks it will be all talk and no action.

The only wild card? Pharmacy Benefit Managers (aka PBMs). The DMCB thinks their value as intermediaries between the pharmaceutical manufacturers and the managed care plans is becoming increasingly commoditized. Their position will become even more tenuous if price controls are pursued by the Obama Administration. To maintain their market share, expect more of them to offer not only disease management services but active support for medical homes on a 'value added' basis without any expectation of lower costs.