According to a new study by the Business Group on Health, over 90% of employers reported concern over high-cost drugs and increasing pharmacy costs. This figure is not surprising when you consider that the average list price increase was nearly $150 per drug in January 2022 and rose to $250 by July 2022. During the twelve-month period from July 2021 to July 2022, the price of 1,216 products surpassed the inflation rate of 8.5%.1
While manufacturer rebates help offset some of these cost increases, rising pharmacy costs pose a significant challenge for health plans, impacting their ability to provide affordable and comprehensive coverage to their members Even a small percentage of specialty pharmacy medications used to treat complex conditions can account for a significant portion of an employer’s pharmacy benefit plan costs – about 50% or more of total prescription spending.2
How can payers help employers make more informed decisions about their prescription benefits programs while staying ahead of these trends?
Employer group reporting is a powerful tool that empowers health plans and their customers to make well-informed decisions, identify cost-saving opportunities, and improve the management of their pharmacy benefit programs. With these advanced reporting capabilities, health plans can gain enhanced visibility into the factors influencing their pharmacy drug spend, all while ensuring that members have access to clinically appropriate prescription medications. The value of employer group reporting extends beyond cost control, offering several key benefits that contribute to the overall success of pharmacy benefit management.
Leverage reliable pharmacy spend data and insights
Relying solely on reports from partners such as pharmacy benefit managers and pharmacy vendors to manage the cost and quality of your pharmacy benefit program may result in missing crucial information. These gaps can hinder your ability to effectively optimize where pharmacy dollars are allocated for your employer groups.
Health plans need to know if their data has integrity issues – i.e. missing data on some percentage of members, having prescription counts but not costs, having too many classifications of “other/unknown,” or relying only on claims data without any pharmacy data at all – so they can avoid taking actions that are ineffective or cause new problems. Employer group reporting aggregates data from various sources such as pharmacy benefit managers (PBMs), health plans, and pharmacies to deliver a more accurate representation of pharmacy spend, allowing health plans to identify trends, patterns, and potential cost-saving opportunities with greater confidence.
Look at both traditional pharmacy and medical pharmacy claims
To gain a larger view of factors driving pharmacy spend, it’s important to have access to pharmacy data from all sources, including those prescriptions processed under the medical benefit. For example, specialty pharmacy drugs often require additional handling and are sometimes administered in a medical setting such as a hospital, resulting in a medical claim. Having access to drugs administered in a medical setting and present only in medical claims data can help employer groups understand and make decisions including whether to promote cost-effective specialty pharmacy delivery services for certain medications. One example of cost-saving measures is the administration of certain drugs in an office setting instead of a more expensive hospital facility. Additionally, opting to have specific medications shipped from an in-network specialty pharmacy can also help reduce costs.
Employer group reporting can help integrate pharmacy and medical pharmacy claims by providing a unified view of an individual’s healthcare utilization. By combining pharmacy claims data with medical claims data, health plans can gain a comprehensive understanding of the medications prescribed, the conditions being treated, and the overall impact on healthcare costs.
Identify at-risk members
Another important point to consider is the outcomes of members who present a combination of health challenges such as being diagnosed with diabetes and/or mental health disorders.
By analyzing high-risk members or high-cost claimants, health plans can determine if there are opportunities to fine-tune benefit plans, increase medication adherence, and promote care management programs.. With the help of employer group reporting, health plans can more closely monitor pharmacy claims data and track the effectiveness of these interventions and make necessary adjustments to optimize outcomes.
Leverage benchmarking and trend analysis
To help employer groups understand how they compare to their peers, benchmarking pharmacy costs and utilization can provide additional insights into how well they are managing pharmacy spend. Account management teams need to identify areas where their clients are either under or over performing to best assess and recommend where their management teams should focus resources and efforts to improve performance.
Benchmarks provide credible external figures to form the basis of these analyses and provide detailed cuts of data specific to pharmacy claims which include generic, brand, specialty, and preventive pharmacy trends and opportunities. A pharmacy benchmark analysis positions you to explore “what if” scenarios and set different utilization targets that could drive to a desired bottom line financial outcome. A recent example involves using utilization benchmarks for glucagon-like peptide-1 (GLP-1) agonists, commonly used to treat Type-2 diabetes, to predict the usage of these drugs in weight loss treatment plans. Employer group reporting can help benchmark pharmacy spend by providing a comparative analysis of pharmacy costs and utilization across different employer groups. Armed with this information, health plans can identify emerging patterns, such as shifts in medication utilization or changes in drug pricing and adjust their pharmacy benefit strategies accordingly.
Employer Group Insights brings it all together
MedInsight’s Employer Group Insights (EGI) application not only enables you to increase the quality and integrity of your pharmacy data but also effectively integrates pharmacy, medical, and other data sources to provide your plan with a more holistic view of its pharmacy management program.
With EGI, health plans can:
- Gain a deeper understanding of pharmacy utilization and costs and identify which areas require additional attention and which benefit plan designs to recommend to employer groups (e.g., prior authorization or step therapy to encourage appropriate utilization and cost controls).
- Identify members who can benefit from additional services to better manage complex therapies and conditions. By ensuring members are actively involved in their treatment plans, health plans and their employer customers can prevent additional medical expenses that may arise from non-adherence to prescribed therapies.
- Understand your future risk based on your pharmacy spend and prepare for emerging drugs by understanding median cost trends for therapies with the same designations (e.g., Orphan, Priority Review, and Accelerated Approval).
Get started today
Speak with one of our employer group reporting experts or request an analytics assessment so you can gain the insights you need to serve your employer group clients more effectively.
- New HHS Reports Illustrate Potential Positive Impact of Inflation Reduction Act on Prescription Drug Prices | HHS.gov
- Health Plans Brace For Specialty Drugs Eclipsing 50% Of Prescription Spending (forbes.com)