Better Together: Integrating Pharmacy And Medical Benefits
Oct 17,2023
Read Time 6 Minutes
Mini-White Paper: Pharmacy Savings And Total Cost Of Care
With pharmacy costs projected to significantly increase over the next several years, many employers continue to look for ways to control costs and create a better employee experience. Is an integrated pharmacy and medical benefits strategy just what the doctor ordered?
Integrating pharmacy benefits with your medical plan may be a way to lower costs and improve your employees' health and healthcare experience. In this mini-white paper, see how data and insights are driving integration decisions for organizations.
Together with your health plan partner, you can use a Total Cost of Care approach to deliver better results for your employees and your organization’s bottom line.
Total Cost of Care
Drive greater value and better outcomes through integrated pharmacy and medical benefits
With pharmacy costs projected to significantly increase over the next several years, many employers continue to look for ways to control costs and create better employee experiences. Learn why an integrated pharmacy and medical benefits strategy could be just what the doctor ordered.
Managing Total Cost of Care
Total Cost of Care (TCOC) refers to the total amount an organization spends on healthcare and health benefits for employees and their dependents. While the concept is straightforward, understanding and managing the variables that impact your organization’s health plan costs can be significantly more complex.
Overall healthcare costs are estimated to rise about 7% in 2024, with approximately 16% of these costs stemming from costly prescription drugs and gene therapies.1 As pharmacy costs increase, organizations need proven strategies and solutions to keep costs in check — as well as keep their employees healthy.
According to a recent study, 99% of large employers said they were concerned about prescription drug trends.2
In recent years, prescription drugs accounted for about 21% of employers’ healthcare costs, with more than half of pharmacy spending going to specialty medications.2
Without a stronger focus on improved care management for your employees, effectively controlling costs for your organization may become increasingly difficult.
Accessing pharmacy data can help
In an effort to reduce costs, many organizations have opted to carve out pharmacy benefits. However, our experience shows that separating medical and pharmacy benefits often causes fragmented care, a negative employee experience, and higher long-term healthcare expenses.
By carving out pharmacy benefits, your health plan lacks timely access to important prescribing data needed to appropriately manage your employees’ care. That’s why an integrated pharmacy and medical benefits strategy can benefit the health of your workforce and your organization.
In 2022, pharmaceutical expenses in the U.S. grew 9.4% compared to 2021, totaling $633.5B. This increase was driven by a 5.9% increase in utilization, a 1.7% increase in price, and 1.8% increase in new drugs.3
Data shows pharmacy integration can lower costs and enhance care quality4
Average industry savings of
- $148 PMPY (per member per year)
- 15% lower hospitalization rates
- 7% fewer emergency room visits
Some Anthem clients who also have our integrated pharmacy solution, CarelonRx, see savings of up to $368 PMPY.
The advantages of integration
An integrated pharmacy strategy can have a positive impact on TCOC. It’s also clear that lower healthcare costs are just one of the many potential benefits.
Here’s how an integrated pharmacy and medical benefits strategy can add significant value for you and your employees.
4 key benefits
- Improved health
- Greater savings
- Seamless employee experiences
- Meaningful value for you
Improved health
Integrated benefits offer the advantage of analyzing both clinical and pharmacy data in real-time, providing valuable insights for optimizing care management and delivering higher-quality care. This includes effectively monitoring chronic conditions, identifying at-risk employees, closing care gaps, and ensuring safe medication usage.
Greater savings
Better care management can also lead to increased savings. Through evidence-based medications and opioid management best practices, care managers can help ensure your employees are using the most clinically effective and safe prescriptions. These efforts support overall employee health and help lower long-term costs, making healthcare more affordable for both your workforce and your organization. For employees who need costly specialty drugs, centers of excellence and intensive care management also produce meaningful savings.
Seamless employee experiences
Besides benefiting your organization, an integrated and well-coordinated plan also simplifies things for your employees. They get a single member ID card, one customer service contact, comprehensive care management, a single digital account, and easy mail-order and retail pharmacy services. These all serve to foster a positive and simplified experience for your workforce.
Meaningful value for you
When medical and pharmacy benefits and data are integrated, you work with one carrier — making plan administration less complex for your organization, too.
Here’s how pharmacy integration can impact your employees
Meet Anthony
Anthony is diagnosed with diabetes and prescribed a new drug. He picks up his new prescription at the pharmacy.
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With integrated pharmacy benefits |
With carved-out pharmacy benefits |
|---|---|
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Anthony’s Anthem care manager reaches out to educate him about his new medication. |
Due to the cost of his prescription, Anthony decides to cut his medication dosage in half. |
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When his prescription is refilled, our analysis of his refill history shows Anthony may be not be taking his medication correctly. |
After experiencing concerning symptoms, Anthony calls his doctor. |
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His care manager contacts him and learns Anthony has been cutting his dosage in half due to the cost. As a result, he’s still experiencing high blood sugar (hyperglycemia). |
Anthony’s doctor believes he’s experiencing a hyperglycemia emergency and suggests going to the emergency room. |
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Anthony’s care manager connects with his doctor to suggest a more affordable, equally effective drug, and his doctor agrees. |
Anthony is admitted to the hospital for treatment of severe hyperglycemia. |
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Anthony picks up his new prescription that now better suits his budget. |
He follows up with his doctor and admits cutting doses in half due to cost; he’s prescribed a new drug with a lower cost. |
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He is staying adherent and showing significantly lower blood sugar, feeling better, and missing less time at work. |
Anthony is on the mend after his ER visit. However, his costly hospital stay, missed workdays, and poor patient experience could have been prevented with better care management through integrated pharmacy benefits. |
Questions? We’re here to help.
We understand that every organization has its own unique needs and challenges. Contact your account management team, broker, or sales representative for more information. Together, we can determine the right Total Cost of Care approach for your organization’s needs.
1 SHRM.org: Employers Anticipate 7% Rise in Health Care Costs for 2024 (accessed August 2023): shrm.org.
2 Business Group on Health: Cancer Now Top Driver of Employer Health Care Costs, Says Business Group’s 2023 Health Care Strategy and Plan Design Survey (accessed August 2023): businessgrouphealth.org.
3 National Library of Medicine: National trends in prescription drug expenditures and projections for 2023 (accessed August 2023): nih.gov.
4 BCBS industry data, 2023.