Such as mental health burdens It increased during the pandemic and even before it, the use of mental health medications has similarly increased. But a new report suggests that more prescriptions don’t necessarily mean higher overall costs.
according to Pharmacy Benefits Innovation Report: Mental Health is HealthHowever, costs per person using mental health medications fell by about 5% between 2020 and 2021, despite increases in overall use of these drugs. The report was released last week by EmpiRx Health, director of value-based pharmacy benefits, based on its claims data.
The report showed that prescriptions for mental health increased by more than 9% between 2020 and 2021, with 75% of those prescribing for antidepressants. However, in the EmpiRx data, increased drug use does not automatically increase costs at the same rate. For example, while antidepressant use increased by 12%, spending per claim increased by less than 2%.
Even more dramatic results were reflected in medication use and costs for attention deficit hyperactivity disorder (ADHD). Use of ADHD medications increased more than 20% year over year, but spending on each ADHD medication claim actually decreased by 9%. Notably, prescriptions for ADHD for adults 26 and older have consistently increased over the past three years, accounting for half of all ADHD drug users.
According to Karthik Ganesh, CEO of EmpiRx Health, the key to the company’s cost reductions lies in the “value-based” approach to pharmacy benefits, not the usual model in the industry.
Pharmacy Benefits Managers (PBMs) Companies that administer prescription drug benefits on behalf of health plans or large employers. The Drug-Based Drug Administration typically develops and administers the list of approved drugs for any particular health plan or group and negotiates drug prices directly with manufacturers. PBMs are, essentially, the drug intermediary that stands between the health plan (and ultimately the consumer) and the drug maker.
according to Commonwealth FundLarge PBMs including CVS/Caremark, ExpressScripts and OptumRx dominate the market with a combined market share of 79%. Newcomers like Marc Cuban Coast Plus Pharmaceutical Company And the civic script They are trying to break into and change market dynamics by specifically lowering the costs of generic drugs.
Traditional PBMs operate on a volume-based model, and you earn more money the more prescriptions you distribute. By buying in bulk and distributing larger quantities of prescription drugs, PBMs are able to negotiate lower prices or better discounts. They share at least part of that savings with their payer – an insurance company or a business owner.
Value-based reimbursement is a healthcare payment model that generally rewards providers of any kind for providing “the right care” to the “right people” at the “right time” (value) rather than rewarding providers for more of whatever service they provide (voice) .
In the context of pharmacy benefits, the value-based model focuses less on the number of prescriptions dispensed and more on ensuring the most appropriate medications are dispensed. This approach may translate to using more detailed description patterns for specific population groups rather than applying general rules across the board. According to Ganesh, value-based pharmacy benefits management often also includes a performance-based component such that a PBM performs better financially when the customer (insurance companies or employer) saves more. In this way, value-based pharmacy benefits management aligns financial incentives in a way that results-based management may not.
Ganesh said this approach reduces waste (or undervalued spending), which is an appreciation a fourth of spending on health care in general and urging others to do the same.
“PBM should usher in a fundamental shift from volume-based, case-oriented models of care to population health management designed with whole person care at its core,” he said.
Ganesh explained that population health management focuses on the health risks of groups of individuals and designs appropriate clinical approaches to improving the health of those groups based on the premise that different populations may need different clinical strategies.
“The population health approach uses the ‘less is more’ model to penetrate what is needed and what may not be necessary for a given population and patient,” Ganesh said.
He argued that pharmacists could play a pivotal role in ensuring the suitability of medications and, ultimately, reducing the costs of prescription drugs to populations and individuals.
“Pharmacists sit at the intersection of patient care, reviewing and evaluating all drug treatments prescribed by various health care providers,” he said. “As the only professional who sees the full picture of medications for a patient and understands their effects, pharmacists are in a privileged position to cash in wasted pharmacy spending for both patients and benefit plan sponsors.”
Because pharmacists know what medications are available and how they work with different people, Ganesh said they are in a good position to identify cost-effective alternatives to more expensive medications.
“By working directly with patients’ physicians, pharmacists influence more accurate prescribing options that prevent high cost without sacrificing care,” he said.