Study: Integrated pharma benefits can cut overall medical costs

According to a recent study, carve-in pharmacy benefits can result in an average savings of $148 per member per year.

Integrated benefits can result in even more savings for those with chronic conditions, including $926 in per-member-per-year for patients with asthma. (Photo: Shutterstock)

For employers looking to take more control of their health care spend, prescription drugs are often a key area of focus. While pharmacy benefits managers have traditionally played gatekeeper between drug manufacturers and employers, more self-insured employers in recent years have been bypassing the middleman to either contract directly with manufacturers or work with their medical provider to take control of these costs.

A recent study provides another incentive for employers to consider an integrated, carve-in pharmacy and medical benefits model: it can lower overall medical spending and lead to fewer hospitalizations and emergency room visits.

Related: Why more employers and insurers are turning to integrated health care

The study, “Medical Costs and Health Care Utilization Among Self-Insured Members with Carve-In Versus Carve-Out Pharmacy Benefits,” appeared in the March edition of the Journal of Managed Care and Specialty Pharmacy. The research was conducted by employees of Cambia Health Solutions and Prime Therapeutics, a pharmacy benefit manager servicing Cambia Health Solutions.

“This is the first time that this kind of work has undergone scientific, peer review,” study author Patrick Gleason, assistant vice president of health outcomes at Prime Therapeutics, said in an interview.

Using anonymous data gathered from 1.6 million members enrolled in Cambia Health Solutions self-insured Blue plans without benefit changes from 2017 through 2018, researchers found that carve-in pharmacy benefits correlated with lower medical costs. Specifically, a 4 percent decrease, or $148, in medical costs per member per year. In addition, odds of being hospitalized decreased 15 percent, and ER visits decreased 7 percent for the study period.

“These findings did not substantially change when high-cost members were removed from analyses,” the authors note, adding that their research found potential for additional savings related to treatment for chronic conditions, including:

To what can we attribute the savings? “When leveraged effectively, integrated data can inform utilization management; authorization decisions; chronic condition care management including medication adherence, behavioral health conditions related to prescription drug abuse, and those conditions served by specialty drugs; and population health management,” the authors write.

P.J. D’Annunzio is a legal reporter at BenefitsPRO parent company ALM Media. 

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