MONICA BERNER: I'm Dr. Berner. I'm a family physician, and I've cared for patients for over a decade. In this podcast series, we take on key health care challenges facing workforces today and what we can do together to address them for employers and their employees. One topic that is a source of extreme complexity and unknowns and also a major driver of health care costs for employers is pharmacy. One overarching question employers wrestle with when it comes to pharmacy benefits and how to best approach them for, both, cost and effectiveness is whether to integrate them with medical benefits or carve them out and cover pharmacy on its own.
I want to welcome my guest today. Dr. Megan Wagner is a pharmacist and serves as a vice president of national employer accounts, specifically focused on pharmacy. Welcome, Megan.
MEGAN WAGNER: Thanks for having me today.
MONICA BERNER: And Kristin Kellas is an expert in management consulting and research analytics and a partner at HealthScape Advisors. She specializes in leveraging data to design and deploy transformative solutions for organizations navigating the increasingly complex health care landscape. Welcome, Kristin.
KRISTIN KELLAS: Happy to be here.
MONICA BERNER: There's so much noise in this space right now, from innovation and new drugs popping up to pharma advertising saturating the airwaves to so much media attention, including news and celebrity endorsements. I'm interested from each of your perspectives on this. What do you think really needs to be in our minds through all the information we're getting? Megan, can you kick us off?
MEGAN WAGNER: Sure. I think it's important to take a step back from all of that and think about these people as patients or members of a plan and think about all of the different things that those people are managing if they have a condition. It might be short term. It might be a chronic condition, but it's not just about taking a medicine maybe that they saw on TV, on a TV commercial, or using some health product that their favorite TikTok influencer recommended.
That member is also trying to manage what to make for dinner for their family that also works with their condition. Or maybe what they saw on TV opened up the door for them to have a conversation with their provider about depression or anxiety or getting to a healthy weight. Those are all important. And then in the framework of all of this, you also have to think about them scheduling time to make appointments and lab tests and picking kids up from school in some cases. And then with the overarching theme of affordability. Can people afford that medicine or that health care visit or those types of things?
So there's a lot to think about even beyond just all the noise that you just referenced. That makes so much sense. Kristin, what comes to your mind?
KRISTIN KELLAS: Yeah, I think echoing Megan's sentiment here on health care is a really personal journey. It's something where it can be really overwhelming with the volume of information that's available. So finding a trusted guide or resource through that journey will really benefit employees and their families in trying to navigate their overall health care experience.
MONICA BERNER: You're right. That is so critical. I think a related idea here is that cost and care are inextricably connected. One risk in this space is when we take this noisy input from so many places, we can lose sight of the human element that you mentioned, Megan. Benefits and care expectations and experiences really need to be connected, and they need to be personal and human so that they're easier to engage and manage.
I often like to think about there being three interconnected aspects. So those pieces are cost, accessibility, and quality. And they really can't be pulled apart. If someone can't afford a medication, they don't have access. And if they don't have access, then they can't have better clinical outcomes. So you can't have one, really, without the other. They're all equally important. Can each of you talk just a little bit more about that need for personalization and the human side of pharmacy benefits and experience?
KRISTIN KELLAS: So I think it's helpful to think about actual situations an employee might be in to really understand the challenges they face in navigating their care and benefits. So it may be something where a recent medical activity of an individual is something as straightforward as going to a doctor's appointment and picking up a medication at their local pharmacy, maybe something more intimidating, like a multi-day hospital stay. This is where if an individual has disconnected benefits, they have two different websites to navigate, potentially two different apps or portals.
They may have different member IDs, login information, passwords. So you're already kind of overwhelmed navigating the complexity of health care. And you're adding additional layer of nuance or change on top of that. In an ideal scenario, an employee can access their information in one, easy-to-consume, frequently updated type place so that there's this really center point or hub of that intel.
MEGAN WAGNER: I think that's a great point and just thinking about that as part of the member experience with a lot of different pieces. We spent a lot of time with our customer service teams dual skilling them so that they can handle both medical and pharmacy questions. So whether a member is calling us or interacting with us digitally, it gives them somebody who can answer all of their questions at one time. And that really helps from reduced transfer time, and you don't have to repeat yourself multiple times to get to an answer that you're looking for. But people are on the phone less, which means they can get back to that soccer game or to a work meeting or whatever they might have going on.
I think some of those pieces are really important. We had a recent example of a member whose employer had been a long-time medical customer and just brought their pharmacy benefits to us. 10 days into the new year, the member called and had some questions about budgeting for his umbrella, a specialty autoimmune medication that he takes for one of his conditions. And he wanted to know if he could keep using his coupon card to help afford because it was really important for them. He was clear that they just had a baby, so they were really careful about their finances.
And the customer advocate could answer all of those questions and was able to run test claims to give them a sense of how much to expect for the year. And then you can hear a baby crying in the background, and he goes, my wife's here, and she has some questions about our medical bills from when the baby was born. So she comes on the phone, and the advocate can answer all the questions about the claims that came through, the billing that came through that was a little bit confusing. And at the end, she handed it back to the husband because the baby started to cry. She needed to go take the baby off. And he was like, wow, I couldn't believe we could get through all of this. It's so nice to be able to take care of all this insurance stuff and just one call.
And so that's just an example of how that integrated data helped to support that advocate take care of that particular member at the time-- actually, both members at the time, to be honest with you. And that's just maybe one example of how to take some of the noise out and make it a little bit simpler for members when you have that connection between medical and pharmacy and the experience and the teams that are supporting those questions.
I think one of the other pieces is part of this is also thinking about how that impacts and supports from a health care or health outcomes, which I think we'll talk about here in a little bit as well.
MONICA BERNER: What a great example. And the personal side can be especially true in complex, chronic, and specialized conditions. I'm wondering if you have any examples of larger data or studies that demonstrate the impact of integration of pharmacy and medical benefits.
MEGAN WAGNER: Yes, we actually did a study with HealthScape in the last couple of years that really looked at self-insured employer groups that have medical and pharmacy benefits connected together, compared to employers that maybe have pharmacy with a different provider, that's not as integrated or connected. And there were really some important pieces that came out of that, one of which we'll talk about is really looking at some of the impact on use of services and utilization of different services, like inpatient stays and those types of things but also looking at impact on certain conditions.
So for example, some of the work in the HealthScape study actually identified that for certain conditions-- we were talking about chronic conditions earlier-- the way that a customer or members with medical and pharmacy benefits connected together actually had about 14% lower medical costs when you have patients that have diabetes or 31% lower medical costs when you have oncology diagnosis. And a lot of that is powered by the data. Having the right data to those clinicians, supporting those members at the right time is really impactful. It kind of navigating the overall health care experience but also getting them to the right providers at the right time.
One example that we can speak to that came through with one of the pharmacy care management teams that we have using some of that integrated data set identified that a member who had a condition called assertive colitis, which is a digestive disorder, was taking a medication called Xeljanz, which by itself was fine. It went through the appropriate process. And the member got their first fill. But our analytics kind of picked up the fact that we also had medical claims on file for that member for chronic kidney disease.
And there's a connection there where the dose needs to really be adjusted for members who have kidney disorders that take this medicine. So the pharmacist was able to connect into the member's health care provider, talk about that. And they both agreed, yeah, we really need to lower the dose on this medicine. So together, they connected with the member and explained, hey, we're going to lower your dose and then worked with the pharmacy to get the prescription transferred over.
And overall, as part of that overall piece, both, the member and the employer wound up having lower costs. But we also prevented some potential additional visits and use of maybe the ER or hospital stay because of that worsening kidney function.
MONICA BERNER: What an incredible combination-- improved clinical outcomes, patient safety, patient satisfaction, and lower costs. Kristin, what are your thoughts about this?
KRISTIN KELLAS: Yeah, so I think as Megan mentioned, what we see in the studies around integration is where employees that can access their medications, and their employees and their families can access medications, they can continue to take their medication, manage their diseases more effectively, this is something where you then may be able to avoid some of those sudden or urgent kind of needs to go to the often-high-cost care settings.
So this is something like an individual that may have diabetes. They're newly diagnosed. They're learning how to monitor their blood sugar. They're adjusting their diet and other lifestyle considerations. So while they're managing this turmoil or change in their health and their daily living, this is where it's important for that individual to have a connected experience into their primary care physician, their endocrinologist, as well as their health plan to understand their access and affordability of the needs of this condition that's just presented itself.
MONICA BERNER: Well, let's talk about the elephant in the room. And there are a lot of employers who are tuning in that are going to wonder about the cost side of the equation. Again, just to reiterate, the HealthScape study showed that ASO groups who carved in pharmacy saw a 9% lower medical costs, not pharmacy costs-- medical costs. And that they saved as much as $516 per member per year. Again, some pretty powerful data.
MEGAN WAGNER: Yeah, that is a big number. 9% doesn't seem like a lot, but it actually is when you think about 9% lower medical costs through that connection. And the things that impact that are like utilization or the use of services. How often, where, all of those things kind of factor in as to the points that you just made too, Kristin. I think that connection and medical data really ties back to you a little bit about what we talked about already, is thinking about, how can you avoid some of those additional higher-cost services by using available data sets to support a member or even a provider who's caring for a member with information at the right time?
Some of the data from that HealthScape study identified that there is actually lower avoidable inpatient admissions when you do have members that have medical and pharmacy connected, and that's 28% lower, which is really impactful. Thinking about a member who's maybe gone in to the hospital and goes back in again within 30 days, the study identified about 4.5% lower risk, which is, again, a small number but really impactful when you think about the cost of a hospital stay and all of the things that are going on, going back to what we talked about at the beginning, a member and all of the things they're juggling with their family and their work life, if they're also juggling at the same time, having to go into a hospital.
So ultimately, with that complete data set, we can better assess risk for our members. And when we can better assess risk, we can predict if a delayed fill of a medication for heart failure, for example, for managing the fluid in somebody's body-- that late fill coupled with maybe an extra ER visit might prompt engagement from one of the nurses as part of our care management team to check in and get that member connected in with her primary care provider and engage perhaps some education about the condition, about taking the medication on time.
And even that example we talked about earlier with the member taking Xeljanz, again, that's an example where we prevented a potential hospitalization due to that risk with kidney failure.
MONICA BERNER: Absolutely. Patient safety, as I mentioned earlier-- I mean, prescription medications are supposed to make patients healthier. But sometimes, if not adhered to properly, if there's not that wraparound care, they can cause problems as well. So Kristin, do you have anything to add?
KRISTIN KELLAS: Yeah, I think that's especially important when we talk about some of the more chronic conditions or where there is a more heavy kind of pharmacy regimen to managing that state. So this is something where certain members with certain cardiac conditions, we saw over $880 per member per year. Some of the cost avoidance or for those with liver disease, it was $3,000 per member per year. So these conditions are incredibly challenging to the individuals that are navigating that and costly.
MONICA BERNER: Can each of you point to two things that you would say employers can think about or ask about or even do right now, whether they're currently at a decision point or looking for potential ways to balance cost and care in terms of pharmacy benefits, what should they take away?
MEGAN WAGNER: I think employers are in a tough spot they need to make, or you need to make responsible decisions about having health care benefits that are affordable and accessible to members. And you're also balancing that as fiduciaries and plan sponsors and making those responsible decisions over time and trying to balance all of that with what's the impact to my members or my employees. How are the programs and solutions that I bring forth actually going to impact outcomes?
So I would say probably the biggest takeaway is to take a moment to consider how that connection between your medical carrier and your pharmacy programs are actually supporting lower costs and having an impact on that member experience and outcomes. And I think, looking at some of those decision points for you, and trying to look at how we can simplify things for members. We talked about at the beginning of how complicated health can be, but trying to offer health benefits that are simpler can really have an impact on employees and members.
KRISTIN KELLAS: Yeah, I think it's really important for employers when they're looking at their portfolio of offerings, to make sure that within that portfolio, they're meeting they're meeting their employees' and their families' needs. So they're looking at whatever they're offering to be affordable and of high quality and accessible. And this is where a key contributor to that is finding the optimal partner that can be part of that portfolio, that can work with you as an employer and your employees and really service their needs.
That's something where, as employers are looking at this decision, making sure that they're really, as we've talked about, taking a step back and seeing their employees and their families as holistic individuals and as patients at the end of the day.
MONICA BERNER: Thank you both. You've given us so much to think about, data driven, personally driven, to make this big decision. We all have a lot of information coming at us when it comes to pharmacy. Integrating medical and pharmacy benefits has been shown to, both, improve outcomes for employees and reduce costs. Despite all the noise surrounding pharmacy, we're here to help cut through the confusion on behalf of employers and their employees.
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