The future of pharmacy care is arriving every day
Does that make you excited, or worried? Both reactions have merit. Medical science is continuing to produce treatments and technologies that were unthinkable not long ago. The way we deliver care is also changing for the better. Technology plays a role there, too.
But the challenges are real. These miraculous treatments won’t pay for themselves. Consumers and plan sponsors alike are left wondering how they will ever manage these accelerating prices.
There’s an old saying that advises, "Be for the future. There’s more of it." At Optum Rx, we are not only embracing the future. We are actively working to create it through leading-edge systems, tools and expertise.
To give you a glimpse of this exciting new world, we have identified four big trends that will make a difference. These trends include a focus on keeping medicines affordable, an expanded role for pharmacists, rising consumer expectations and the rapid advance of medical science. Given that the impact of many of these trends are still ongoing, it is reasonable to assume the rapid pace of evolution seen in pharmacy care services is likely to persist for the foreseeable future.
1. An increased focus on affordability
Any assessment of the future of pharmacy must begin with accounting for whether people needing medicines will be able to afford them. As drug costs have continued to rise in recent years, this question has become less rhetorical. A recent survey found 47% of people now acknowledge they have skipped a medication or refill due to cost.1
With this need in mind, we are creating tools that help minimize barriers to care for members.
A recent survey indicated 70% of consumers have shopped around for the best drug price.2 Launching early in 2023, Optum Rx Price Edge is designed to help consumers find the best price, whether on or off the pharmacy benefit. For a given drug, this innovative offering compares a member’s on-benefit cost-share with the prices available via discount cards. It then adjudicates to the lower cost in real time. For drugs not covered under the pharmacy benefit, Price Edge offers direct-to-consumer discounts. These savings improve the member experience and reinforce the value of the pharmacy benefit, all at no program cost to clients or members.
For people with chronic conditions, even a short interruption of therapy can have a significant impact on health outcomes. Drugs contained within the Optum Rx Critical Drug Affordability modules have a maximum member cost share of $35 per month supply. By limiting member out-of-pocket expenses, these modules help sever the link between rising member cost share and lower medication adherence.3
Affordability is also a future concern for plan sponsors. Optum Rx has a broad spectrum of clinical programs that plan sponsors can leverage to achieve substantial savings and safeguard the benefit.
One recent innovation is the Optum Rx® Polypharmacy Value Management Program. Using analytics to identify potential instances of medication overload, our pharmacists perform comprehensive medication reviews with eligible members. Then, with their consent, pharmacists contact their provider to evaluate opportunities to stop using medications based on member response and other clinical information.
This consultative approach can help prevent side effects and potential adverse drug events for members. It also lowers costs from unnecessary medicines for plan sponsors.
These are but a few of the many ways we are building the capabilities and services necessary to make sure clients and members can afford the medications of tomorrow.
2. The expanded role of the pharmacist
The nation’s more than 320,000 pharmacists have long been at the forefront of health care. Data indicates patients interact with pharmacists almost twice as often as they do with a physician.4
As the tools of pharmacy continue to evolve, so too will the role of the pharmacist. Pharmacy automation is expected to more than double by 2030. This use of automation will allow pharmacists to spend more time on virtual and physical patient care.
This expanded role will include initiating therapies and having greater flexibility in deciding which drug to dispense. For example, in July 2022, the U.S. Food and Drug Administration revised the Emergency Use Authorization (EUA) for Paxlovid™ (nirmatrelvir and ritonavir), to authorize state-licensed pharmacists to prescribe Paxlovid to eligible patients, under certain conditions.5
With the potential designation as a health care provider, pharmacists will play an expanded and more active role treating patients in a holistic manner. This new role may also help offset a looming shortage of physicians.6 An expanded role for pharmacists will also be welcomed by patients, with more 80% of patients already considering them an integral part of their health care team.7
Therefore, pharmacists are uniquely positioned to prevent medication adverse effects. For example, a study found that a pharmacist-managed anticoagulation service had significantly fewer adverse events than the comparison group. This resulted in $3,700 overall cost savings per patient.8
Additionally, engagement with pharmacists drives medication adherence. A study found that effective use of pharmacists resulted in a 30% improvement in medication adherence.9
Pharmacists can also play a leading role in educating patients about less expensive medications. This will increasingly include biosimilar options for biologic drugs.
Taken together, these actions show how pharmacists are poised to improve the affordability and sustainability of pharmacy benefits and reduce the total cost of care for patients and payers.
3. Rising consumer expectations
From the patient perspective, visible seams have long existed between the medical, behavioral, wellness, and pharmacy facets of their care. This has resulted in inefficiencies and potential gaps in care.
Consumer expectations have evolved in the era of mobile devices and ubiquitous e-commerce. They now expect a seamless, omnichannel experience to find and access high-quality, affordable medication options. For PBMs and health care providers, meeting these expectations means investing in the digital tools necessary to offer simplified, frictionless access to prescription medications for patients.
One prime example of how the drive to a more consumer-centric future has accelerated in recent years is the increased adoption of telemedicine, as seen during the pandemic. Going forward, more than 40% of adults indicate that they would like to continue to use telemedicine services post-pandemic.10
From now on, all aspects of health care will be more seamlessly integrated as consumers demand easier ways to navigate and support their care. This better integration and more holistic care coordination will especially benefit those with chronic diseases.
Take for example diabetes, where unhealthy behavior and lifestyle choices can result in poor adherence to diabetes medications and poor health outcomes. To combat this, the Optum Rx Diabetes Management Program features an integrated approach. It pairs member engagement, education and weight loss support with case management provided by certified diabetes educators from Optum Rx. The result is clinical improvement, higher member satisfaction and medical cost savings.
4. Advancement of medical science
One trend already beginning to impact pharmacy care services is the availability of new types of therapies unavailable if not unimaginable just a few years ago. While cellular therapies such as (CAR) T-cell therapy for cancers are becoming more commonplace, advances such as gene therapies are approaching on the horizon.
By silencing or replacing malfunctioning genes, gene therapies have the potential to cure previously untreatable genetic diseases. By curing rather than simply managing the symptoms of a disease, gene therapies can avoid years of costly treatments and hospitalizations and lower total cost in the long run. However, these benefits must be weighed against the significant upfront costs of these therapies. For example, one of the first gene therapies, Zolgensma®, launched in 2019 with a price tag exceeding $2 million.11 In August 2022, the FDA approved Zynteglo®, which bears a price of $2.8 million.12 In September 2022, the FDA approved another gene therapy, Skysona®, which costs $3 million.13
Currently, only a few gene therapies are approved for use in the U.S. However, this won’t be the case for very long. There are 900 gene therapies currently undergoing clinical studies.14 Given this, as many as 10–20 gene therapies are expected to be approved by 2025.15 To help payers prepare for a future where gene therapies are more commonplace, Optum Gene Therapy Risk Protection is designed to provide patients appropriate access to gene therapies while helping plan sponsors manage the financial risk and volatility presented by these ultra-high-cost drugs.
In addition to the new gene therapies, we can also look for increased use of precision medicines. These drugs are tailored to the highly personalized needs of each patient — right down to the genetic level. Also known as pharmacogenomics, this field of study examines how a person's genetic makeup affects how they respond to a given medication and will become more prevalent as the cost of genetic testing continues to decline.
Wider use of pharmacogenomics should help reduce total care costs by identifying exactly who will — or will not — benefit from a medicine before it is used. This prevents costly adverse drug events and side effects, as well as eliminates the cost of ineffective drug regimens. For example, one study found that using pharmacogenetics in guiding therapy resulted in a greater than 50% increase in response rate to initial antidepressant treatment.16 This resulted in significant cost savings as the treatment costs for managing non-responders were estimated to be $10,000 higher per year.17
Finally, AI and machine learning present an emerging opportunity to improve outcomes and lower the cost of care. Indeed, 98% of health care executives say they have or are planning to implement an AI strategy.
With these tools, multiple data sets, including pharmacy, medical, lab, demographic, social, behavioral and environmental data, can be merged and analyzed. This will allow pharmacy benefit managers to proactively identify opportunities for targeted interventions at the patient level.
Indeed, Optum Rx has created a unified data infrastructure capable of capturing, structuring and analyzing this data. We then use predictive modeling and machine learning to determine the best health and savings opportunities at the best time for each member.
For example, our diabetes progression machine learning model runs on pharmacy claims data and was trained using integrated pharmacy and medical data. The model can predict the probability of diabetes-related hyperglycemic events in the next 2 years at the patient level. This enables Optum Rx to prioritize engagement with high-risk members in our diabetes management program and help them avoid complications related to diabetes such as vascular disease, coronary artery disease, kidney disease and eye problems.
In addition, our predictive non-adherence machine learning model uses Optum Rx data assets to predict the likelihood an individual will become non-adherent to their medication in the next 120 days. This data gives us an opportunity to intervene before a person becomes non-adherent.
It’s important to remember that these trends aren’t happening in isolation. Rather, these and other factors will overlap and combine to define how much pharmacy changes for payers and patients alike in the years ahead.
To make the most of these future forces, Optum Rx believes that collaboration with payers, providers and members alike is essential. Talk to your Optum Rx partner to learn more ways we can work together to help you prepare for the future of pharmacy care services.
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STATEMENT REGARDING FINANCIAL INFLUENCE:
This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor Optum Rx has accepted any form of compensation for the preparation or distribution of this article.
- Single Care. Over 800 Drugs Increase in Price in 2022.
- Optum Healthier Connection Study, 04/2021
- Journal of Managed Care & Specialty Pharmacy. Novel Type 2 Diabetes Medication Access and Effect of Patient Cost Sharing.
- Journal of Managed Care & Specialty Pharmacy. Pharmacists as accessible health care providers: quantifying the opportunity.
- FDA. Emergency Use Authorization 105.
- Pharmacy Times. The Societal Case for Pharmacist Provider Status.
- Policy & Medicine. Pharmacists’ Role to Expand Over the Next Decade
- Pharmacotherapy. Health care expenditures and therapeutic outcomes of a pharmacist-managed anticoagulation service versus usual medical care.
- Healthcare Financial Management Association. How pharmacists can play a role in curtailing the rising cost of drug therapy.
- Becker Hospital Review. 7 Stats that Show how Americans Used Telehealth in 2021
- BioPharmaDive. First oral drug for spinal muscular atrophy approved by FDA.
- Reuters. Bluebird's $2.8 million gene therapy becomes most expensive drug after U.S. approval.
- Fierce Pharma. A $3M gene therapy: Bluebird bio breaks its own pricing record with FDA approval of Skysona.
- FDA. FDA Continues Strong Support of Innovation in Development of Gene Therapy Products
- FDA. Statement from FDA Commissioner Scott Gottlieb, M.D. and Peter Marks, M.D., Ph.D., Director of the Center for Biologics Evaluation and Research on new policies to advance development of safe and effective cell and gene therapies.
- Frontiers in Pharmacology. Pharmacogenetics in Psychiatry: An Update on Clinical Usability.