A Single Pharmacy Benefit

AJPB® Translating Evidence-Based Research Into Value-Based Decisions®, March/April 2011, Volume 3, Issue 2

A pharmacy benefit that covers both inpatient and outpatient medications would ensure safe, cost-effective care in an integrated, automated way across all healthcare venues.

In the November 2010 issue of The American Journal of Pharmacy Benefits, I wrote about using the pharmacy benefit management (PBM) platform to address the issue of medication reconciliation and to bridge the chasm between medical silos. In this issue, I want to discuss the pharmacy benefit in the context of those medical silos. Today, the pharmacy benefit covers medications prescribed in the outpatient setting. I believe that the benefit not only addresses financial issues but also acts as a safety net for safety and appropriateness. What would happen if we broadened the PBM methodology to cover not only ambulatory medications but also medications prescribed within the inpatient setting? Let me paint a scenario.

A patient with diabetes goes into the hospital for a cardiac problem. He is on a blood pressure medication and a diabetes medication. These medications, prescribed by his primary care physician and his cardiologist, are preferred medications according to the formulary of the PBM company and are automatically reviewed for safety by the PBM system. As a result, the patient receives cost-effective medications, which according to the article “The Implications of Choice” by Shrank et al,1 helps to support medication adherence. It also assures the patient that the medications that are prescribed by his primary care physician and his cardiologist will not negatively interact with each other or create redundancies. While in the hospital the patient receives 2 additional medications prescribed by the hospitalist caring for him. The medications are appropriate but are not on the preferred list of the formulary. The information associated with these new medications is not run through the patient’s PBM system prior to the patient leaving the hospital. It is possible that the patient’s physicians are not aware that the patient was placed on the new medications.

If the pharmacy benefit covered both inpatient and outpatient medication therapy, the medications prescribed by the hospitalist could be either adjudicated or analyzed across the pharmacy benefit system. Thus, the PBM company could address the issues associated with cost, safety, and redundancy. It would also enable information on all the prescribed medications to be housed in a single location. The PBM information would be availablefor both outpatient and inpatient providers to access.

Why has this model not been contemplated? I do not have an answer for that question. Payers are responsible for the cost of the medications regardless of where they are prescribed. Why would they not want a method that ensures safe, cost-effective care in an integrated, automated way across all venues in healthcare?

Why have we segmented medication systems across service lines? I look forward to hearing your thoughts. It is time we take the best models in healthcare and create a real system in order to maximize care.