- Email: [email protected]
Evaluation of the economic and clinical impact of community pharmacist-driven pharmacy benefit management services
SCIENCE AND PRACTICE Journal of the American Pharmacists Association 59 (2019) S91eS94
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Evaluation of the economic and clinical impact of community pharmacist-driven pharmacy benefit management services Deven L. Jackson, Natasha M. Michaels, Brad Melson, Evan Bruder, Laura A. Rhodes, Macary Weck Marciniak* a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 September 2018 Accepted 26 March 2019 Available online 13 June 2019
Objective: To evaluate the economic and clinical impact of community pharmacisteled pharmacy benefit management (PBM) services. Setting: Independent community pharmacy in western North Carolina. Practice description: Sona Benefits is a PBM partner to self-funded plans in western North Carolina. The services provided by Sona Benefits are led by pharmacists at its affiliate company, Sona Pharmacy þ Clinic. Practice innovation: In October 2016, Sona Benefits began providing PBM services to members employed by a local continuing care retirement community. Evaluation: Economic outcome measures included change in total medical and prescription costs per member per year (PMPY) and change in cost per prescription from baseline. Change in clinical outcome measures (hemoglobin A1C, weight, blood pressure) was assessed for members who participated in 2 or more quarterly health coaching sessions. Results: Prescription costs were reduced from $1219.72 to $858.57 PMPY and medical health care costs were reduced from $5910.76 to $4290.30 PMPY from baseline. This represented a total decrease of $1981.61 PMPY in health care costs. A reduction in the average cost per prescription from $95.10 to $61.88 was observed. For patients enrolled and active in health coaching, we observed reductions in weight, hemoglobin A1C, and blood pressure. Between the initial and final health coaching visits, average weight decreased from 204.6 lb (92.8 kg) to 203.6 lb (92.4 kg), the percentage of patients at hemoglobin A1C goal increased from 47% to 53%, and percentage of patients at goal for blood pressure increased from 58% to 78%. Conclusion: Inclusion of community pharmacists in PBM service delivery produced economic benefits for plan sponsors. Preliminary clinical data suggested benefits of pharmacist-led health coaching services, but further evaluation is needed to determine the long-term impact. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Disclosures: Macary Marciniak declares that her spouse is employed by the American Pharmacists Association. The remaining authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. Contributions: Conceptualization (all), data curation (D.L.J.), formal analysis (D.L.J., L.A.R.), funding acquisition (all), investigation (D.L.J., N.M.M., B.M., E.B.), methodology (all), project administration (all), resources (D.L.J., N.M.M., B.M., E.B.), supervision (all), validation (all), visualization (all), writing original draft (D.L.J.), review and editing (all). Previous presentation: The results of this work have been reported at the American Pharmacists Association Annual Meeting and Exposition, Nashville, TN, March 2018, and the Research in Education and Practice Symposium, Chapel Hill, NC, May 2018. * Correspondence: Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 115G Beard Hall, Campus Box 7574, Chapel Hill, NC 27599-7574. E-mail address: [email protected] (M.W. Marciniak).
Data from the Centers for Medicare and Medicaid Services indicate that the United States spent $3.5 trillion, or $10,379 per person, on health care in 2017. Projections from this data indicate that health care costs are expected to grow at an average rate of 5.5% annually through 2026.1 Stakeholders throughout the health care ecosystem are working to reduce costs and create a sustainable health care delivery system. Noted strategies to reduce health care costs include improving preventative care efforts, reducing costs of prescription drugs, and eliminating unnecessary medical procedures.2 Pharmacy benefits managers (PBMs) represent a possible solution to rising drug costs. PBMs are third-party administrators who work with health plans and employer groups to manage prescription drug benefits for members affiliated with
https://doi.org/10.1016/j.japh.2019.03.016 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE D.L. Jackson et al. / Journal of the American Pharmacists Association 59 (2019) S91eS94
Key Points Background: Community pharmacists are well positioned to support a value-based health care model. Pharmacy benefit managers (PBMs) are entities that function to reduce pharmacy benefit costs while working to improve outcomes for members. PBMs serve as an avenue for community pharmacists to provide clinical services such as health coaching. Findings: Pharmacist-led PBM services can reduce per member per year health care costs to plan sponsors. Preliminary clinical data additionally suggest benefit of pharmacist-led health coaching services for patients with targeted disease states. Further evaluation is needed to determine the longterm economic and clinical impact of partnerships between PBMs and community pharmacists.
a given plan. PBMs work in a variety of roles, including processing of prescription drug claims, developing and maintaining drug formularies, and negotiating contracts between pharmacies and pharmaceutical manufacturers. In addition to the benefits that result from their administrative functions, PBMs also offer clinical services such as health coaching and medication management. This suite of services is designed to provide better care to members and lower health care costs. Pharmacists are well positioned and trained to provide nondispensing patient care services, including medication therapy management (MTM), immunizations, and health coaching services. A meta-analysis of the impact of MTM provided by community pharmacists showed a reduction of medication therapy problems and reductions in health care costs; however, the evidence included in this analysis was insufficient to show consistently improved health outcomes from pharmacy MTM services.3 In addition to services such as MTM, pharmacists can also provide innovative clinical services for patients, such as disease state health coaching. The impact of pharmacist care services in the community setting was the focus of several studies in the past, including The Asheville Project and Diabetes Ten City Challenge. Each of these studies provided insight on the economic outcomes for plan sponsors and clinical outcomes for patients as a result of a community pharmacistedriven diabetes care program. The first of these studies, The Asheville Project, was a landmark study that demonstrated the multifaceted significance of pharmacist care services; many of these results were reproduced in the Diabetes Ten City Challenge. Of note, these studies both found that community pharmacist services led to statistically significant decreases in hemoglobin A1C and low-density lipoprotein cholesterol.4,5 Similar to The Asheville Project and Diabetes Ten City Challenge, Sona Benefits offers health coaching services for targeted disease states to
S92
improve outcomes for members and to decrease health care costs. Despite the robust evidence of clinical benefit of community pharmacisteled clinical services, the data pertaining to the economic and clinical impact of PBM services led by community pharmacists are lacking. To better understand these benefits, we conducted a retrospective analysis of economic and clinical data for the members of our pharmacist-run PBM. Objectives The primary objective of this study was to evaluate the economic impact for beneficiaries of Sona Benefits, defined as the change in total medical and prescription expenses per member per year (PMPY) and the change in cost per prescription. The secondary objectives were to evaluate change in percent generic medication utilization and clinical impact of patients enrolled in the pharmacist-led health coaching services available to Sona Benefits members. Practice description Established in 2016, Sona Benefits is a PBM subsidiary of Blue Ridge Pharmacy, which is an independent community pharmacy group composed of long-term care, retail, compounding, and specialty pharmacies located in western North Carolina. Sona Benefits provides traditional PBM services such as customizable plan design, transparent pass-through pricing, and brand-generic substitution. In addition, Sona Benefits also provides pharmacist-led medication management and health coaching. All the services provided by Sona Benefits are led by pharmacists employed by Sona Pharmacy þ Clinic, the community pharmacy arm of Blue Ridge Pharmacy. Health coaching services are provided at the member’s preference at the member's place of work or at Sona Pharmacy þ Clinic. All other PBM services are provided by Sona Pharmacy þ Clinic. Practice innovation Medication management services provided by pharmacists was comprised of bimonthly evaluation of prescription claims to identify intervention opportunities. These interventions were aimed at providing members with medications that maintained quality of care and, in most cases, reduced costs to the plan or member, or both. For example, brand-to-generic substitution and utilization of compounded products are mechanisms to reduce prescription costs. Key focuses of health coaching appointments were medication adherence, disease state assessment, meal planning, physical activity, sleep, and smoking cessation. At each appointment, members participating in health coaching established personalized health goals and plans to achieve these goals. Health coaching services were on an appointment-based model in which meetings typically lasted 1 hour each. The pharmacist health coach providing these services received consent to receive patient laboratory data. The goals for blood pressure and hemoglobin A1C were personalized and established collaboratively by the pharmacist health coach and providers. These goals were consistent with evidence-based guidelines, such as the American
SCIENCE AND PRACTICE Economic and clinical evaluation of PBM services
Table 1 Change in prescription and medical costsa Timeframe January 2015 to December 2015 October 2016 to September 2017 PMPY change from baseline
Prescription Costs PMPY
Medical Costs PMPY
Total Cost PMPY
$1219.72 $858.57 $361.15
$5910.76 $4290.30 $1620.46
$7130.48 $5148.87 $1981.61
Abbreviation used: PMPY, per member per year. a Prescription and medical cost data were included for all members of this plan at the time of evaluation.
Diabetes Association Standards of Medical Care in Diabetes and Joint National Committee 8.6-8 Members were self-identified for health coaching during the open enrollment period while meeting with a Sona Benefits representative. Members were incentivized to participate in health coaching services with reduced copayments for medications. Enrollment in health coaching required that patients fill all maintenance medications at Sona Pharmacy þ Clinic to ensure continuity of care. Evaluation Data sources We examined the first year of services provided to one plan sponsor managed by Sona Benefits, from October 1, 2016, through September 30, 2017. This plan covers an average of 545 lives per month, including employees, their spouses, and dependents. The number of lives covered from month to month varied for several reasons, such as new employment or terminations. Economic data came from Sona Benefits’ database of pharmacy claims managed by a third-party administrator. Clinical data were gathered from notes maintained by pharmacists at Sona Pharmacy þ Clinic and laboratory data from outside health care providers. The Institutional Review Board at the University of North Carolina at Chapel Hill determined that this study was nonehuman subjects research and exempted it from review. Economic and clinical measure analysis For the economic evaluation, all covered lives were evaluated. For the clinical outcome analysis, only patients offered health coaching and who received at least 2 sessions were included. Patients with diabetes, asthma, chronic obstructive pulmonary disease, cardiovascular disease, depression, or autoimmune conditions were eligible for health coaching. To evaluate economic impact, PMPY costs from October 1, 2016, through September 20, 2017, were compared with PMPY costs from January 1, 2015, through December 31, 2015. This baseline was chosen because it was the last complete calendar year of data for medical and prescription claims available for evaluation. Results The total PMPY costs during the baseline period were $7130.48. During the evaluation period PMPY costs decreased $1981.61, resulting in total costs of $5148.87. The breakdown of PMPY costs can be found in Table 1. Assuming this plan covered 545 covered lives, Sona Benefits saved this plan sponsor $1.08
million over the course of the year. Cost per prescription for plan sponsors decreased from $95.10 to $61.88. Health coaching was provided to a total of 88 members with a mean age of 53.5 years. Of these members, 73 had data available for analysis, including 73 for blood pressure and weight and 17 for hemoglobin A1C. The data for remaining patients were not available because of termination of employment, withdrawal from coaching, and unenrollment from health coaching. The members included for evaluation participated in at least 2 quarterly health coaching appointments with an average of 5.5 months in the program. Average blood pressure was reduced from 126/76 mm Hg to 122/73 mm Hg. Average weight was reduced from 204.6 lb (92.8 kg) to 203.6 lb (92.4 kg). Average hemoglobin A1C was reduced from 7.5% to 7.2%. In addition, compared with baseline, more patients met goals for both hemoglobin A1C and blood pressure (Table 2). Percent generic utilization increased from 84.8% at baseline to 87.1%. Discussion To our knowledge, this study is the first to report a reduction in PMPY costs from PBM services, such as medication management and health coaching, provided in partnership with an independent community pharmacy group. The provision of PBM services by Sona Benefits, including pharmacist-led services such as medication management and health coaching, resulted in a reduction in PMPY costs. In addition to the economic benefits observed, we observed a modest clinical benefit for members participating in health coaching services. Although not directly evaluated, the proposed primary mechanism for reducing medical costs PMPY was a reduction in unnecessary medical care (e.g., hospitalizations) for members in health coaching; proposed mechanisms for reducing prescription costs PMPY were Sona Benefits’ pricing model, formulary design, and increase in generic utilization. Table 2 Change in targeted clinical measures for members in health coaching Measure Hemoglobin A1C (N ¼ 17) Mean hemoglobin A1C Member hemoglobin A1C at goal, n (%) Blood pressure (N ¼ 73) Mean blood pressure, mm Hg Member blood pressure at goal, n (%) Mean weight, lb (kg, N ¼ 73)
Initial appointment
Last appointment
7.5% 8 (47)
7.2% 9 (53)
126/76 42 (58)
122/73 57 (78)
204.6 lb (92.8 kg)
203.6 lb (92.4 kg)
Members were included in this evaluation if they had participated in at least 2 quarterly health coaching appointments. Blood pressure and weight measurements were observed by pharmacist health coaches at each health coaching appointment; hemoglobin A1C values were obtained from each member’s primary care provider.
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SCIENCE AND PRACTICE D.L. Jackson et al. / Journal of the American Pharmacists Association 59 (2019) S91eS94
The economic and clinical benefits seen for members are in line with the results of aforementioned studies such as The Asheville Project and Diabetes Ten City Challenge, including decreases in health care costs and improvement of targeted clinical measures.4,5 The actual claims data for this plan indicate that PMPY savings were realized in addition to modest clinical improvements seen for members in health coaching. Of note, PMPY savings were evaluated for all members of this plan; an ongoing evaluation is in progress to quantify the PMPY savings specifically for members in health coaching. A strength of our study is the ability to estimate the economic impact of our intervention; however, this study has several limitations. We examined the impact on only one plan with a relatively small number of covered lives in one geographic area, which could affect the generalizability of our results to other PBMs and other plan sponsors. Furthermore, our analysis considered the full suite of services offered by Sona Benefits and we are unable to determine the impact of each service in isolation. Our examination of the clinical outcomes is also limited by our small sample size, limited duration of follow-up, and limited ability to control for confounders. In addition, because the blood pressure at baseline was close to goal for many members, the marginal decrease in mean blood pressure could be the result of regression to the mean or other factors and thus account for the increase in members at goal. The rising cost of health care supports the use of pharmacists in nondispensing roles. Because of their unique skill set and accessibility, pharmacists have the potential to provide quality patient care while reducing health care costs. Sona Benefits is unique in its inclusion of community pharmacists in all PBM service delivery, but the data to support the long-term benefits are still lacking. Future studies are needed to determine whether pharmacist-led PBM services consistently and reliably decrease health care costs. Careful attention to potential confounders should be considered, as should standardized procedures for quantifying the impact of pharmacist interventions. Lastly, efforts to attribute health care cost savings to specific PBM services would provide valuable insight on the expected impact of nontraditional services, such as health coaching. Conclusion Community pharmacists are uniquely positioned to provide PBM services for members and plan sponsors. Inclusion of
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community pharmacists in a PBM provides an opportunity to generate decreases in PMPY medical costs for plan sponsors. The limited preliminary clinical data suggest benefit of pharmacist-led health coaching services; however, further evaluation and data are needed to determine their long-term impact, including on other covered disease states, such as asthma.
References 1. Centers for Medicare and Medicaid Services. National Health Expenditure Data. Available at: https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/NationalHealthExpendData/index. html. Accessed January 2, 2018. 2. Dalen JE. We can reduce US health care costs. Am J Med. 2010;123: 193e194. 3. Viswanthan M, Kahwati LC, Golin CE, et al. Medication therapy management interventions in outpatient settings: a systematic review and metaanalysis. JAMA Intern Med. 2015;175:76e87. 4. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173e184. 5. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc. 2009;49:383e391. 6. American Diabetes Association Standards of Medical Care in Diabetese 2016. Diabetes Care. 2016;39(suppl 1):S1eS112. 7. American Diabetes Association Standards of Medical Care in Diabetese 2017. Diabetes Care. 2017;40(suppl 1):S1eS134. 8. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507e520. Deven L. Jackson, PharmD, Clinical Coordinator, Sona Pharmacy þ Clinic, Asheville, NC; at the time of study, PGY1 Community-based Pharmacy Resident, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, and Sona Pharmacy þ Clinic, Asheville, NC Natasha M. Michaels, PharmD, BCACP, Director of Clinical Services and Residency Site Coordinator, Sona Pharmacy þ Clinic, Asheville, NC Brad Melson, PharmD, General Manager and Residency Preceptor, Sona Pharmacy þ Clinic, Asheville, NC Evan Bruder, Director of Business Development, Sona Pharmacy þ Clinic, Asheville, NC Laura A. Rhodes, PharmD, BCACP, Assistant Professor of Pharmacy Practice, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL; at the time of study, Community Practice Engagement Fellow, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Clinical Associate Professor and Director, PGY1 Community-based Pharmacy Residency Program, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Evaluation of the economic and clinical impact of community pharmacist-driven pharmacy benefit management services Deven L. Jackson, Natasha M. Michaels, Brad Melson, Evan Bruder, Laura A. Rhodes, Macary Weck Marciniak* a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 September 2018 Accepted 26 March 2019 Available online 13 June 2019
Objective: To evaluate the economic and clinical impact of community pharmacisteled pharmacy benefit management (PBM) services. Setting: Independent community pharmacy in western North Carolina. Practice description: Sona Benefits is a PBM partner to self-funded plans in western North Carolina. The services provided by Sona Benefits are led by pharmacists at its affiliate company, Sona Pharmacy þ Clinic. Practice innovation: In October 2016, Sona Benefits began providing PBM services to members employed by a local continuing care retirement community. Evaluation: Economic outcome measures included change in total medical and prescription costs per member per year (PMPY) and change in cost per prescription from baseline. Change in clinical outcome measures (hemoglobin A1C, weight, blood pressure) was assessed for members who participated in 2 or more quarterly health coaching sessions. Results: Prescription costs were reduced from $1219.72 to $858.57 PMPY and medical health care costs were reduced from $5910.76 to $4290.30 PMPY from baseline. This represented a total decrease of $1981.61 PMPY in health care costs. A reduction in the average cost per prescription from $95.10 to $61.88 was observed. For patients enrolled and active in health coaching, we observed reductions in weight, hemoglobin A1C, and blood pressure. Between the initial and final health coaching visits, average weight decreased from 204.6 lb (92.8 kg) to 203.6 lb (92.4 kg), the percentage of patients at hemoglobin A1C goal increased from 47% to 53%, and percentage of patients at goal for blood pressure increased from 58% to 78%. Conclusion: Inclusion of community pharmacists in PBM service delivery produced economic benefits for plan sponsors. Preliminary clinical data suggested benefits of pharmacist-led health coaching services, but further evaluation is needed to determine the long-term impact. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Disclosures: Macary Marciniak declares that her spouse is employed by the American Pharmacists Association. The remaining authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. Contributions: Conceptualization (all), data curation (D.L.J.), formal analysis (D.L.J., L.A.R.), funding acquisition (all), investigation (D.L.J., N.M.M., B.M., E.B.), methodology (all), project administration (all), resources (D.L.J., N.M.M., B.M., E.B.), supervision (all), validation (all), visualization (all), writing original draft (D.L.J.), review and editing (all). Previous presentation: The results of this work have been reported at the American Pharmacists Association Annual Meeting and Exposition, Nashville, TN, March 2018, and the Research in Education and Practice Symposium, Chapel Hill, NC, May 2018. * Correspondence: Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 115G Beard Hall, Campus Box 7574, Chapel Hill, NC 27599-7574. E-mail address: [email protected] (M.W. Marciniak).
Data from the Centers for Medicare and Medicaid Services indicate that the United States spent $3.5 trillion, or $10,379 per person, on health care in 2017. Projections from this data indicate that health care costs are expected to grow at an average rate of 5.5% annually through 2026.1 Stakeholders throughout the health care ecosystem are working to reduce costs and create a sustainable health care delivery system. Noted strategies to reduce health care costs include improving preventative care efforts, reducing costs of prescription drugs, and eliminating unnecessary medical procedures.2 Pharmacy benefits managers (PBMs) represent a possible solution to rising drug costs. PBMs are third-party administrators who work with health plans and employer groups to manage prescription drug benefits for members affiliated with
https://doi.org/10.1016/j.japh.2019.03.016 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE D.L. Jackson et al. / Journal of the American Pharmacists Association 59 (2019) S91eS94
Key Points Background: Community pharmacists are well positioned to support a value-based health care model. Pharmacy benefit managers (PBMs) are entities that function to reduce pharmacy benefit costs while working to improve outcomes for members. PBMs serve as an avenue for community pharmacists to provide clinical services such as health coaching. Findings: Pharmacist-led PBM services can reduce per member per year health care costs to plan sponsors. Preliminary clinical data additionally suggest benefit of pharmacist-led health coaching services for patients with targeted disease states. Further evaluation is needed to determine the longterm economic and clinical impact of partnerships between PBMs and community pharmacists.
a given plan. PBMs work in a variety of roles, including processing of prescription drug claims, developing and maintaining drug formularies, and negotiating contracts between pharmacies and pharmaceutical manufacturers. In addition to the benefits that result from their administrative functions, PBMs also offer clinical services such as health coaching and medication management. This suite of services is designed to provide better care to members and lower health care costs. Pharmacists are well positioned and trained to provide nondispensing patient care services, including medication therapy management (MTM), immunizations, and health coaching services. A meta-analysis of the impact of MTM provided by community pharmacists showed a reduction of medication therapy problems and reductions in health care costs; however, the evidence included in this analysis was insufficient to show consistently improved health outcomes from pharmacy MTM services.3 In addition to services such as MTM, pharmacists can also provide innovative clinical services for patients, such as disease state health coaching. The impact of pharmacist care services in the community setting was the focus of several studies in the past, including The Asheville Project and Diabetes Ten City Challenge. Each of these studies provided insight on the economic outcomes for plan sponsors and clinical outcomes for patients as a result of a community pharmacistedriven diabetes care program. The first of these studies, The Asheville Project, was a landmark study that demonstrated the multifaceted significance of pharmacist care services; many of these results were reproduced in the Diabetes Ten City Challenge. Of note, these studies both found that community pharmacist services led to statistically significant decreases in hemoglobin A1C and low-density lipoprotein cholesterol.4,5 Similar to The Asheville Project and Diabetes Ten City Challenge, Sona Benefits offers health coaching services for targeted disease states to
S92
improve outcomes for members and to decrease health care costs. Despite the robust evidence of clinical benefit of community pharmacisteled clinical services, the data pertaining to the economic and clinical impact of PBM services led by community pharmacists are lacking. To better understand these benefits, we conducted a retrospective analysis of economic and clinical data for the members of our pharmacist-run PBM. Objectives The primary objective of this study was to evaluate the economic impact for beneficiaries of Sona Benefits, defined as the change in total medical and prescription expenses per member per year (PMPY) and the change in cost per prescription. The secondary objectives were to evaluate change in percent generic medication utilization and clinical impact of patients enrolled in the pharmacist-led health coaching services available to Sona Benefits members. Practice description Established in 2016, Sona Benefits is a PBM subsidiary of Blue Ridge Pharmacy, which is an independent community pharmacy group composed of long-term care, retail, compounding, and specialty pharmacies located in western North Carolina. Sona Benefits provides traditional PBM services such as customizable plan design, transparent pass-through pricing, and brand-generic substitution. In addition, Sona Benefits also provides pharmacist-led medication management and health coaching. All the services provided by Sona Benefits are led by pharmacists employed by Sona Pharmacy þ Clinic, the community pharmacy arm of Blue Ridge Pharmacy. Health coaching services are provided at the member’s preference at the member's place of work or at Sona Pharmacy þ Clinic. All other PBM services are provided by Sona Pharmacy þ Clinic. Practice innovation Medication management services provided by pharmacists was comprised of bimonthly evaluation of prescription claims to identify intervention opportunities. These interventions were aimed at providing members with medications that maintained quality of care and, in most cases, reduced costs to the plan or member, or both. For example, brand-to-generic substitution and utilization of compounded products are mechanisms to reduce prescription costs. Key focuses of health coaching appointments were medication adherence, disease state assessment, meal planning, physical activity, sleep, and smoking cessation. At each appointment, members participating in health coaching established personalized health goals and plans to achieve these goals. Health coaching services were on an appointment-based model in which meetings typically lasted 1 hour each. The pharmacist health coach providing these services received consent to receive patient laboratory data. The goals for blood pressure and hemoglobin A1C were personalized and established collaboratively by the pharmacist health coach and providers. These goals were consistent with evidence-based guidelines, such as the American
SCIENCE AND PRACTICE Economic and clinical evaluation of PBM services
Table 1 Change in prescription and medical costsa Timeframe January 2015 to December 2015 October 2016 to September 2017 PMPY change from baseline
Prescription Costs PMPY
Medical Costs PMPY
Total Cost PMPY
$1219.72 $858.57 $361.15
$5910.76 $4290.30 $1620.46
$7130.48 $5148.87 $1981.61
Abbreviation used: PMPY, per member per year. a Prescription and medical cost data were included for all members of this plan at the time of evaluation.
Diabetes Association Standards of Medical Care in Diabetes and Joint National Committee 8.6-8 Members were self-identified for health coaching during the open enrollment period while meeting with a Sona Benefits representative. Members were incentivized to participate in health coaching services with reduced copayments for medications. Enrollment in health coaching required that patients fill all maintenance medications at Sona Pharmacy þ Clinic to ensure continuity of care. Evaluation Data sources We examined the first year of services provided to one plan sponsor managed by Sona Benefits, from October 1, 2016, through September 30, 2017. This plan covers an average of 545 lives per month, including employees, their spouses, and dependents. The number of lives covered from month to month varied for several reasons, such as new employment or terminations. Economic data came from Sona Benefits’ database of pharmacy claims managed by a third-party administrator. Clinical data were gathered from notes maintained by pharmacists at Sona Pharmacy þ Clinic and laboratory data from outside health care providers. The Institutional Review Board at the University of North Carolina at Chapel Hill determined that this study was nonehuman subjects research and exempted it from review. Economic and clinical measure analysis For the economic evaluation, all covered lives were evaluated. For the clinical outcome analysis, only patients offered health coaching and who received at least 2 sessions were included. Patients with diabetes, asthma, chronic obstructive pulmonary disease, cardiovascular disease, depression, or autoimmune conditions were eligible for health coaching. To evaluate economic impact, PMPY costs from October 1, 2016, through September 20, 2017, were compared with PMPY costs from January 1, 2015, through December 31, 2015. This baseline was chosen because it was the last complete calendar year of data for medical and prescription claims available for evaluation. Results The total PMPY costs during the baseline period were $7130.48. During the evaluation period PMPY costs decreased $1981.61, resulting in total costs of $5148.87. The breakdown of PMPY costs can be found in Table 1. Assuming this plan covered 545 covered lives, Sona Benefits saved this plan sponsor $1.08
million over the course of the year. Cost per prescription for plan sponsors decreased from $95.10 to $61.88. Health coaching was provided to a total of 88 members with a mean age of 53.5 years. Of these members, 73 had data available for analysis, including 73 for blood pressure and weight and 17 for hemoglobin A1C. The data for remaining patients were not available because of termination of employment, withdrawal from coaching, and unenrollment from health coaching. The members included for evaluation participated in at least 2 quarterly health coaching appointments with an average of 5.5 months in the program. Average blood pressure was reduced from 126/76 mm Hg to 122/73 mm Hg. Average weight was reduced from 204.6 lb (92.8 kg) to 203.6 lb (92.4 kg). Average hemoglobin A1C was reduced from 7.5% to 7.2%. In addition, compared with baseline, more patients met goals for both hemoglobin A1C and blood pressure (Table 2). Percent generic utilization increased from 84.8% at baseline to 87.1%. Discussion To our knowledge, this study is the first to report a reduction in PMPY costs from PBM services, such as medication management and health coaching, provided in partnership with an independent community pharmacy group. The provision of PBM services by Sona Benefits, including pharmacist-led services such as medication management and health coaching, resulted in a reduction in PMPY costs. In addition to the economic benefits observed, we observed a modest clinical benefit for members participating in health coaching services. Although not directly evaluated, the proposed primary mechanism for reducing medical costs PMPY was a reduction in unnecessary medical care (e.g., hospitalizations) for members in health coaching; proposed mechanisms for reducing prescription costs PMPY were Sona Benefits’ pricing model, formulary design, and increase in generic utilization. Table 2 Change in targeted clinical measures for members in health coaching Measure Hemoglobin A1C (N ¼ 17) Mean hemoglobin A1C Member hemoglobin A1C at goal, n (%) Blood pressure (N ¼ 73) Mean blood pressure, mm Hg Member blood pressure at goal, n (%) Mean weight, lb (kg, N ¼ 73)
Initial appointment
Last appointment
7.5% 8 (47)
7.2% 9 (53)
126/76 42 (58)
122/73 57 (78)
204.6 lb (92.8 kg)
203.6 lb (92.4 kg)
Members were included in this evaluation if they had participated in at least 2 quarterly health coaching appointments. Blood pressure and weight measurements were observed by pharmacist health coaches at each health coaching appointment; hemoglobin A1C values were obtained from each member’s primary care provider.
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The economic and clinical benefits seen for members are in line with the results of aforementioned studies such as The Asheville Project and Diabetes Ten City Challenge, including decreases in health care costs and improvement of targeted clinical measures.4,5 The actual claims data for this plan indicate that PMPY savings were realized in addition to modest clinical improvements seen for members in health coaching. Of note, PMPY savings were evaluated for all members of this plan; an ongoing evaluation is in progress to quantify the PMPY savings specifically for members in health coaching. A strength of our study is the ability to estimate the economic impact of our intervention; however, this study has several limitations. We examined the impact on only one plan with a relatively small number of covered lives in one geographic area, which could affect the generalizability of our results to other PBMs and other plan sponsors. Furthermore, our analysis considered the full suite of services offered by Sona Benefits and we are unable to determine the impact of each service in isolation. Our examination of the clinical outcomes is also limited by our small sample size, limited duration of follow-up, and limited ability to control for confounders. In addition, because the blood pressure at baseline was close to goal for many members, the marginal decrease in mean blood pressure could be the result of regression to the mean or other factors and thus account for the increase in members at goal. The rising cost of health care supports the use of pharmacists in nondispensing roles. Because of their unique skill set and accessibility, pharmacists have the potential to provide quality patient care while reducing health care costs. Sona Benefits is unique in its inclusion of community pharmacists in all PBM service delivery, but the data to support the long-term benefits are still lacking. Future studies are needed to determine whether pharmacist-led PBM services consistently and reliably decrease health care costs. Careful attention to potential confounders should be considered, as should standardized procedures for quantifying the impact of pharmacist interventions. Lastly, efforts to attribute health care cost savings to specific PBM services would provide valuable insight on the expected impact of nontraditional services, such as health coaching. Conclusion Community pharmacists are uniquely positioned to provide PBM services for members and plan sponsors. Inclusion of
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community pharmacists in a PBM provides an opportunity to generate decreases in PMPY medical costs for plan sponsors. The limited preliminary clinical data suggest benefit of pharmacist-led health coaching services; however, further evaluation and data are needed to determine their long-term impact, including on other covered disease states, such as asthma.
References 1. Centers for Medicare and Medicaid Services. National Health Expenditure Data. Available at: https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/NationalHealthExpendData/index. html. Accessed January 2, 2018. 2. Dalen JE. We can reduce US health care costs. Am J Med. 2010;123: 193e194. 3. Viswanthan M, Kahwati LC, Golin CE, et al. Medication therapy management interventions in outpatient settings: a systematic review and metaanalysis. JAMA Intern Med. 2015;175:76e87. 4. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173e184. 5. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc. 2009;49:383e391. 6. American Diabetes Association Standards of Medical Care in Diabetese 2016. Diabetes Care. 2016;39(suppl 1):S1eS112. 7. American Diabetes Association Standards of Medical Care in Diabetese 2017. Diabetes Care. 2017;40(suppl 1):S1eS134. 8. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507e520. Deven L. Jackson, PharmD, Clinical Coordinator, Sona Pharmacy þ Clinic, Asheville, NC; at the time of study, PGY1 Community-based Pharmacy Resident, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, and Sona Pharmacy þ Clinic, Asheville, NC Natasha M. Michaels, PharmD, BCACP, Director of Clinical Services and Residency Site Coordinator, Sona Pharmacy þ Clinic, Asheville, NC Brad Melson, PharmD, General Manager and Residency Preceptor, Sona Pharmacy þ Clinic, Asheville, NC Evan Bruder, Director of Business Development, Sona Pharmacy þ Clinic, Asheville, NC Laura A. Rhodes, PharmD, BCACP, Assistant Professor of Pharmacy Practice, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL; at the time of study, Community Practice Engagement Fellow, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Clinical Associate Professor and Director, PGY1 Community-based Pharmacy Residency Program, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC