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Step 3: Enhance Patient Outcomes and Improve Patient Experience

As an industry, PBMs prioritize patient affordability and encourage the use of lower-cost generic and biosimilar products, as well as lower-cost brand drugs that produce the same clinical benefits for patients. PBMs have one primary function, lowering drug costs. PBMs currently generate $148 billion in savings for the U.S. economy annually. The savings generated result in lower cost sharing for patients, lower, more stable premiums, broader drug coverage, increased patient adherence, and better patient outcomes. Patient cost sharing is a function of plan design, and PBMs offer and encourage myriad options to support patient affordability.

PBMs use their expertise in benefit administration, rapidly advancing technology, and clinical prowess to ensure the right patient gets the right drug in a timely manner. The process begins with bringing together pharmacists, physicians, and other clinicians who use their specialized knowledge to evaluate prescription drugs and make recommendations to help provide people access to the safest, most effective drug to meet their needs. Then clinical data is used to support decision-making and help patients stay on course with their prescription therapy through evidence-based medication adherence and health coaching programs, all the way to the point of sale (POS) where PBMs help pharmacies enhance patient safety, prevent potentially harmful drug interactions, and reduce the unnecessary dispensing of medications. Patients also benefit from offerings like home delivery—saving time and money while increasing access and care coordination, and medication management programs designed to provide support, promote health literacy, provide better safety [include URAC stats on home delivery vs retail error rates in callout box], and improve patient outcomes. And every PBM offers myriad options for plan sponsors to choose from to help patients save money at the pharmacy counter.

According to the TRICARE Pharmacy Home Delivery program contractor, prescriptions filled through the TRICARE Pharmacy Home Delivery program were 99.997% free of clinical errors, such as shipping the incorrect pharmaceuticals, while retail pharmacy programs were 98.5% error free.

To preserve and enhance these benefits, PCMA recommends the following:

  • Improve outcomes through programs such as medication therapy management (MTM) and assessment, which targets patients who are on multiple medications and can benefit from improving the use of medications.
  • Having a pharmacist available 24/7 to answer questions about medications.
  • Evaluating the appropriate use of medications by conducting a drug utilization review (DUR) for patients for all drugs billed to the PBM.
  • Working with home delivery and specialty pharmacies to ensure high-quality service and improve access to medications, adherence rates, and outcomes.
  • Create adherence, safety, and patient assistance programs.
  • Offering technological assistance, including software and phone applications to help patients understand and properly take their medications.
  • Design, provide, and perform care coordination for patients with complicated diseases and therapies, such as partnering with home infusion services, social or behavioral therapists, and other care providers.
  • Defining the term “telepharmacy” as “The provision of pharmacist care by a pharmacist through the use of telecommunications and other technologies. Such care may include dispensing and distribution of prescription drugs, drug utilization review, patient counseling services, specific drug therapy and comprehensive medication monitoring, and any other pharmacy service function that can be executed with the assistance of technology.”
  • Expanding the availability of telepharmacy to include a consistent framework of brick-and-mortar remote sites staffed with non-pharmacist employees empowered to practice at the top of their licenses or certifications (e.g., receiving and inputting prescriptions into the pharmacy’s information management system and preparing prescriptions for dispensing) with remote supervision from a pharmacist and self-service automated machines capable of accepting prescriptions or refilling orders, storing prepackaged or repackaged medications, and labeling and dispensing patient-specific prescriptions. This will advance health equity by supporting rural communities as well as other areas with insufficient pharmacy support.
  • Guiding Principles for Responsible AI Usage
  • Define AI as “a branch of computer science that uses data processing systems that perform functions normally associated with human intelligence, such as reasoning, learning, and self-improvement, or the capability of a device to perform functions that are normally associated with human intelligence such as reasoning, learning, and self-improvement.”
  • Support responsible industry use of AI in accordance with the Organisation for Economic Co-operation and Development (OECD) Principles on Artificial Intelligence, U.S. Department of Commerce’s National Institute of Standards and Technology (NIST) Artificial Intelligence Risk Management Framework, and existing laws, regulations, and consumer protections as PBMs develop and use AI systems.
  • Foster collaboration between NIST and other standards-development organizations to further develop and refine voluntary, consensus-based industry standards, as well as risk-based frameworks and best practices.
  • Promote harmonization, cooperation, and collaboration to reduce fragmentation in regulatory and supervisory approaches across jurisdictions.
  • Preserve the ability to use AI to provide patients and providers information to alert them to potential health-related risks or issues to explore, support informed clinical decision-making, protect patient privacy and security, manage administrative functions, support patient access, and engage consumers.
  • Support the use of “human-in-the-loop” models and repeatable governance processes or frameworks, where applicable, to address current gaps in the interoperable governance environment. 
  • Promote transparency in the use of AI in patient care, including information on any potential limitations of the AI tool(s), and provide safeguards to protect patient privacy.
  • Require consumer advertisements for drugs and biologics covered under Medicare or Medicaid to include the drug’s list price in all marketing mediums.
  • Prohibit drug manufacturers from deducting direct-to-consumer advertising expenses from their federal tax returns.
  • Start confirmatory trials earlier. Require drug companies to initiate phase 4 confirmatory trials prior to granting approval under the Accelerated Approval review process.
  • Enforce research schedules. Ensure that drug company research schedules are closely adhered to with predetermined monitoring checkpoints and swift penalties for delays.
  • Empower the FDA to take enforcement action against drugs that do not demonstrate appropriate clinical efficacy. 
  • Enable value-based payment arrangements (VBP) in all markets. Enable payers to explore outcomes-based payment arrangements in both the public and private markets. 
    • Avoid policies that could disincentivize VBP.
  • Require clinical trials to reflect the diversity of the patient population expected to use the product, including through expanding eligibility criteria and reducing the burden on trial participants, as well as community-based collaboration.
  • Standardize and incentivize demographic data collection to allow stratification. Stratifying data collected from clinical trials will help payers optimize outcomes-based agreements.
  • Improve interagency collaboration to align CMS processes like coverage determinations with the FDA’s approval processes.

Guiding Principles for Responsible AI Usage

Use, Validity, and Reliability

Set and adhere to the highest standards for the equitable use of AI to analyze data to provide safe and secure products and services to customers and clients in a manner that preserves flexibility.

Develop reliable and valid AI systems that are accurate and mindful of minimizing negative impacts to care and management processes, treatments, and diagnostic services to improve the health and vitality of patients.

Secure, Resilient Privacy Protections

Maintain a privacy-focused design in AI technology development and usage ensuring appropriate confidentiality data protections.

Ensure confidentiality, integrity, and availability through protection mechanisms that prevent unauthorized access and use.

Fairness and Equitable Treatment

Work to identify and mitigate potential harmful bias or disparate treatment throughout all algorithmic and AI applications.

Safety

Guarantee through testing, re-testing, and regular review across the life cycle that AI solutions are fair, compliant, safe, secure, auditable, and human-centered.

Incorporate human oversight or augmented intelligence and controls relative to AI.

Accountability and Transparency

Commit to responsible use by adoption of internal governance, based on national and international risk-based frameworks.

Deploy explainable and interpretable systems with effective monitoring and auditing regimes.

Support measured reporting requirements, such as attesting to the use of fairness and bias testing as part of internal governance to protect consumers from unintended consequences with the risk of privacy and security concerns from sharing broad data sets that include protected information, and the risk of intellectual property (“IP”) concerns from sharing trade secrets such as algorithms.
Back to Affordable Future

Sources

CAQH. (2020) The 2019 CAQH Pharmacy Services Index. https://www.caqh.org/hubfs/43908627/drupal/explorations/index/index-pharmacy-brief.pdf

 Mulligan, C. (2022) The Value of Pharmacy Management. https://www.nber.org/papers/w30231.

NIST. https://csrc.nist.rip/Topics/Technologies/artificial-intelligence