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Connecting Medical and Pharmacy Benefits to Improve Care and Lower Costs

People’s health and well-being are tied to many things, including diet and exercise, family history, and the care and medication they get for physical and mental health conditions. It’s all connected. 

Health care, though, may be divided among many providers, including doctors, therapists and pharmacists, who may not have the same information at the same time. Health insurance, too, may be fragmented between medical and pharmacy benefits.

With connected pharmacy and medical benefits, teams at Blue Cross and Blue Shield of Texas are better able to help members achieve their best health.

BCBSTX's pharmacists identify when members haven’t picked up prescriptions, aren’t taking medications as prescribed or not refilling prescriptions on time. They also look for opportunities to help lower members’ prescription costs and keep them healthier.

“We take a holistic view, reviewing their medications and their diagnosis to identify areas where we can optimize the members’ therapies,” says Tomi Mamora, a value-based care pharmacist and manager.

“By connecting medical and pharmacy benefits, employers can really unlock the full potential of lowering their health care costs, and they can improve their employee health care outcomes.”

The value of this approach is enhanced when these teams have real-time access to data across the member’s medical and pharmacy benefits, says Jill Firch, divisional senior vice president of pharmacy. 

Many people may not realize it, but a group health plan’s pharmacy benefit manager may be separate from the insurer administering the medical benefits. 

“People shouldn't have to think about the difference between a medical and a pharmacy benefit. They should be connected,” Firch says. “By connecting medical and pharmacy benefits, employers can really unlock the full potential of lowering their health care costs, and they can improve their employee health care outcomes.”

Connected benefits allow for real-time medical, behavioral health and pharmacy data analysis to help maximize management of chronic conditions, close care gaps and monitor prescription use and potential interactions.

“You basically have the same focus on the medical side and the pharmacy side to come together with one thing in mind, which is to help the member through their journey of taking care of their health,” says Tina Thompson, a pharmacist and director medical integration. “When a member has a medical condition, if we can catch them while they're in the early stages and make sure they adhere to their medication, the member is going to have better health outcomes.”

Members with connected benefits were 4.5% less likely to be readmitted after a hospital stay, likely because of early identification and higher engagement with care management, according to a study conducted by a consulting firm for BCBSTX.

For employers, connecting pharmacy and medical benefits can help rein in increasing health care and prescription costs, Firch says. High-cost specialty drugs and common chronic conditions such as diabetes present significant challenges for employers trying to support workers’ health and lower their health care costs.

Large employer groups with integrated pharmacy and medical benefits saved an average of $516 per member per year in medical costs compared with those that didn’t, according to the three-year study, which tracked 6.4 million commercial members.

Medical costs significantly decreased for members with chronic conditions including diabetes, cancer and rheumatoid arthritis.

Because of the pharmacy care management program’s success, company leaders looked for opportunities to expand it throughout the year, Firch says.

“We remain steadfast on connecting medical and pharmacy benefits where employers have every opportunity to unlock the full potential of lowering their overall health care spending, while ensuring that their employees remain healthy, improve health outcomes and have an enhanced the member experience,” she says. “We're looking at their employee, our member, through a medical and a pharmacy lens, leveraging any sort of data that we have in-house to be proactive in our care management programs to more effectively monitor and improve the overall costs to our members.”

A 2020 study published in the Journal of Managed Care & Specialty Pharmacy also affirmed the value of connecting patient medical and pharmaceutical benefits. Researchers found that patients with integrated benefits had lower medical costs, fewer hospitalizations and higher engagement in care management.

Drug benefits that are “carved out,” as it’s known in the industry, may contribute to fragmented health care and higher long-term costs.

For example, a pharmaceutical care management team wouldn’t know that someone stopped taking a diabetes medication until claims data revealed a higher level of medical intervention was needed to control a member’s condition, says Dr. Tony Vancauwelaert, executive medical director for pharmacy and medical operations.

“The quality of care has decreased for that person,” says Vancauwelaert, a former primary care doctor. “If the quality has gone down, the cost is going go up. And that's something that affects all of us.”

“We have a lot of very high-cost, critical conditions that we manage in health care today,” Thompson says. “If we can actually help the member to gain access to their drugs on their pharmacy benefit, we can prevent escalations that are caused by a crashing medical condition.”

The analysis performed for BCBSTX showed members with connected pharmacy benefits had a 154% higher engagement rate with its pharmaceutical care management pharmacists than those with carved-out benefits.

Mamora says members appreciate her team’s efforts to help them. For instance, her team assisted a member and the member’s medical provider avoid a harmful drug interaction by identifying the issue and recommending a safer alternative medication.

“The biggest place where we make a difference is in being able to have that holistic view of the members' medications and medical conditions and then provide our opinion on how we can optimize the member's therapy,” Mamora says. “The members are really grateful that someone else is looking out for them and having that person who's helping them navigate their health care journey.”

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association