As mental health burdens increased during and even before the pandemic, the use of mental health medications also increased. But a new report suggests that more prescriptions don’t necessarily mean higher overall costs.
According to the Innovation in Pharmacy Benefits: Mental Health is Health report, costs per person using mental health medications decreased by nearly 5% between 2020 and 2021, despite increases in overall use of these medications. The report was released last week by EmpiRx Health, a value-based pharmacy benefit manager, based on its claims data.
The report showed that prescriptions related to mental health increased by more than 9% between 2020 and 2021, with 75% of these prescriptions for antidepressants. However, in the EmpiRx data, this increase in drug use did not automatically drive costs up at the same rate. For example, while the use of antidepressants increased by 12%, the expenditure per claim increased by less than 2%.
Even more dramatic results were reflected in the drug use and costs of Attention Deficit Hyperactivity Disorder (ADHD). ADHD medication use is up more than 20% year-over-year, but spending per ADHD medication claim is actually down 9%. Notably, ADHD prescriptions among adults 26 and older have steadily increased over the past three years, accounting for half of all ADHD medication users.
According to EmpiRx Health CEO Karthik Ganesh, the key to the company’s cost reductions lies in the “value-based” approach to pharmaceutical benefits, which is not typical in the industry.
Pharmacy Benefit Managers (PBMs) are companies that manage prescription drug benefits on behalf of health plans or large employers. PBMs typically establish and manage the list of approved drugs for a given health plan or group and negotiate drug prices directly with manufacturers. PBMs are, essentially, the drug middleman that stands between the health plan (and ultimately the consumer) and the drug manufacturer.
According to the Commonwealth Fund, large PBMs, including CVS/Caremark, ExpressScripts and OptumRx, dominate the market with a combined market share of 79%. New entrants such as Mark Cuban’s Cost Plus Drug Company and CivicaScript are trying to break in and change market dynamics by specifically reducing generic drug costs.
Conventional PBMs operate on a volume-based model, earning more money the more prescriptions they dispense. By buying in bulk and dispensing larger volumes of prescription drugs, PBMs are able to negotiate lower prices or better discounts. They share at least part of these savings with the payer, an insurer or an employer.
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 provide more services than they offer. (volume).
In the context of pharmaceutical benefits, a value-based model focuses less on the number of prescriptions dispensed and more on ensuring that the most appropriate drugs are dispensed. This approach can translate into the use of prescription models more suited to specific populations rather than the application of general rules at all levels. According to Ganesh, value-based pharmaceutical benefit management often incorporates a performance-based component as well, so that PBM does better financially when the client (insurers or employer) saves more. In this way, value-based pharmacy benefit management aligns financial incentives in a way that conventional PBMs cannot.
Ganesh said this approach reduces waste (or low-value spending), which accounts for around a quarter of overall health spending and urged others to follow suit.
“PBMs must make a fundamental shift from volume-based, condition-focused models of care to personalized population health management with holistic 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 improve the health of these groups on the basis that different populations may need different strategies. different clinics.
“A population health approach uses a ‘less is more’ model to narrow down what is needed and what may be unnecessary for a specific population and patient,” Ganesh said.
He argued that pharmacists can play a pivotal role in ensuring the appropriateness of medicines and ultimately reducing prescription drug costs for populations and individuals.
“Pharmacists sit at the intersection of a patient’s care, reviewing and evaluating all drug therapies prescribed by various health care providers,” he said. “As the only professionals who see the full picture of patient medications and understand its implications, pharmacists are in a unique position to eliminate unnecessary pharmaceutical expenses for patients and benefit plan sponsors.
Because pharmacists know what drugs are available and how they work for different people, Ganesh said they are in a good position to identify cost-effective alternatives to more expensive drugs.
“By working directly with patients’ physicians, pharmacists influence more accurate prescribing choices that avoid excessive costs without sacrificing care,” he said.
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