Navigating the Future: The Pivotal Role of Managed Care Pharmacy in Shaping Health Outcomes

The Academy of Managed Care Pharmacy (AMCP) recently released its second annual report, Access, Affordability and Outcomes: The Value of Managed Care Pharmacy. In the report, AMCP looked at the concepts of managed care pharmacy and provides insight and clarity into today’s changing health care climate and how it can be navigated to improve both patient care and outcomes.

While the report offers a deep dive into challenges faced by managed care pharmacy and opportunities available, some of the key areas of focus included in the report were: current spending on prescriptions, statistics on health insurance and prescription drug coverage, prescription utilization and out-of-pocket spending, managed care pharmacy tools and their impact, and pharmacy types and pharmacy networks.

Generally speaking, “managed care” is “a health care delivery system organized to manage cost, utilization, and quality,” and managed care plans aim to reduce costs while keeping quality high by using provider networks, prescription drug tiers, and other forms of utilization management.

Tools Available to Managed Care

The report explored several managed care pharmacy tools, including prior authorization, step therapy, and medication therapy management. The report noted that while one of the major critiques of prior authorization is the amount of time and effort required of providers and their staff to obtain authorizations, it is not every single drug subject to prior authorization. AMCP conducted a study in June 2019 that found prior authorization to be helpful, particularly in cases where there are: specific safety concerns; availability of more affordable alternatives; a potential for off-label use; a potential for misuse or abuse; or limited distribution or special handling requirements.

With respect to step therapy, the report cited an Avalere study that researched the use of step therapy for high-cost, specialty medications by 17 of the largest commercial health plans in the United States, finding that 38.9% of drug coverage policies applied step therapy, though the proportion of each plan’s coverage policies that included step therapy varied by plan, ranging from 20.6% to 57.5%. The research noted that the average number of steps was 1.5, with 66.6% of policies requiring a single step, 22.7% requiring two steps, 7.6% requiring three steps, and 3.1% requiring four or more steps.

For Medicare, the use of step therapy in Medicare Part D is substantially lower than in the commercial market. According to the Medicare Payment Advisory Commission (MedPAC), just 1% of drugs in the standalone PDP and MA-PD plans were subject to step therapy. In 2019, 45 out of 50 states reported using step therapy in their Medicaid programs.

Pharmacy Types

When looking at mail order pharmacies, the report found that patient savings varied from mail order pharmacies to community pharmacies (with a 90-day supply), depending on the type of medication. When patients use a mail order pharmacy to receive their 90-day supply of medication, the average patient savings for: brand medications reimbursed by commercial payers was 13%, generic medications reimbursed by commercial payers was 22%, and brand medications reimbursed by Medicare was 12%. For community pharmacies, the average patient savings for: brand medications reimbursed by commercial payers was 32%, generic medications reimbursed by commercial payers was 23%, and brand medications reimbursed by Medicare was 7%.

Additionally, the report found that patients who used mail order pharmacies for 90-day supplies had the highest adherence to prescribed protocols, with 83% of patients using mail order pharmacies reaching minimum days covered standards when compared to other dispensing methods.

The report further found significant differences in cost for specialty drugs, driven by the site of care. For three specific physician-administered drugs (Prolia, Entyvio, and Ocrevus), the report found “significantly higher costs” to plan sponsors in the HOPD setting relative to the pharmacy setting. When compared to administration in an office setting, the difference in cost to plan sponsors was less significant and varied depending on the drug.

Conclusion

In conclusion, the report notes, “Managed care pharmacy tools play an important role in improving clinical outcomes, ensuring the appropriate use of medications, and containing rising costs.” Based on the forecast that prescription drug spending is likely to increase in the coming years, “[t]his growth will be driven by the emergence of innovative, potentially life-changing therapies, but many of those will come with a high cost. Managed care pharmacy’s role is to ensure those costs are reasonably contained while ensuring patients can access critical therapies. Managed care pharmacy tools play a key role in achieving the balance between access and cost.”