One of the main challenges within thehealthcare industry – finding the right balance between drug discovery and drug pricing ultimately makes or breaks the business. Private plans find themselves facing the same challenges as government programs (Medicare and Medicaid) when it comes to fund the prescription drug needs of those covered by the plans. While today’s market offers a plethora of options for prescription drugs, it has left patients and healthcare plan members confused about the pricing andbenefitsrelated to their healthcare plans.
Given that employers, healthcare providers, and third-party administrators are unlikely to undergo a disruptive change in their health plans, the goal was to facilitateeffective providing medication coverage without significantly altering their healthcare plans. Pursuingthis quest to defeat the ever-increasing costs in the world of Pharmacy Benefits comesELMC Rx solutions. ELMCRxstands apart from its peers and empowers employers and healthcare plans by offering transparency in drug pricing and better member engagement. The Pennsylvania based firm payers including private employers, government entities and union trust funds mitigate the clinical and financial risks while preserving the program benefits for the members.
With the acquisition of Tesser Health last year, ELMC Rx has successfully expanded its prescription drug cost management programs to cover all drugs under an employer’s plan, specialty, high cost and lower cost medication alike. “We protect the plan financially and safeguard the members clinically,” says John Adler, President of ELMC Rx Solutions. ELMC creates pathways for people who write checks for specialty and non-specialty medication. “Clients who take advantage of our full suite of cost containment services are able to achieve up to an 18 to 22 percent reduction in drug cost annually,” adds Adler. The firm’s experience and expertise in medical stop loss, prescription drug stop loss, reinsurance, and underwriting and consulting allow it to protect its clients from financial and clinical risks. For instance, a member who was being treated for hemophilia was experiencing a skyrocketing increase in the cost of medication. During problem analysis, ELMCRx Solutions zeroed in on the prescribed dosage as the primary factor in the increasing medical bill. Empowered by the ELMC Risk Solutions, the healthcare plan could take data-driven decisions and eventually save $400,000 per year as dosing was brought to the appropriate level. Similarly, ELMC’s clinical pharmacists closely review each PBM’s clinical guidelines to verify that approvals made by the PBMs comply with these guidelines. For the majority of approvals, the guidelines are followed, but when there is a detour, it can be meaningful to the member and plan sponsor. As new therapies are approved to supplement namebrand drugs, ELMCRx ensures that generics are the first line drugs approved, in accordance with PBM guidelines and clinical guidelines. Further explaining the processof significant cost reduction in drugs, Adler highlights, “We felt very early on that if we can bring price transparency and member engagement with interactive tools, we can help membersunderstand their drugs, how much they cost, where they could get their drugs cheaper, and then alternatives to their medications.And that’s been a 10-yearmission of mine personally.”Adding the component of peer to peer discussion has also helped ELMCRx achieve buy in from prescribers. This collaborative approach is critical to success under the company’s Specialty and Non- Specialty programs.
Solving the problems at the granular level, ELMCRxSolutions studies multiple datapoints at the outset. It provides tools and technology that allow the users to understand the drug pricing and know the providers of cheaper drugs. Equipped with this knowledge, the users can alter medication and its dosing and duration. They can also compare the generic drugs and change one for the other. Eventually, ELMC Rx Solutions reduces the cost of medication for the entire healthcare network that comprises patients and healthcare plans. “Our ultimate goal is to preserve the member benefits,” adds Adler. Moreover, the pharmacy benefit managers on the clinical prior authorizations have moved to electronic prior authorizations, which are driven by algorithms. While this has inevitably taken much of the human component out of the equation, “we are dissecting the results of those clinical prior authorizations and bringing experienced doctors of pharmacy into play in the evaluation before the drug is dispensed. And that was that an algorithm cannot possibly pick up all of the nuances in the complicated conditions, and the complicated analysis and the things that need to be done,” shares Adler.
By intervening in the process with a real-time before high cost medications are dispensed, adjustments can be mad. Unlike medical plan overpayments, there is no ability to truly recover prescription drug overpayments. Payers must manage cost, dosage and clinical guidelines before the member receives the medication.
The company not only helps the clients in multiple problem areas but also leaves a positive influence on the financial and clinical decisions of the healthcare plan members. Showcasing ELMCRx’s prowess in delivering effective cost management,Adler sharedan interesting case study. In this instance, a member was using widely prescribed Humira,one of the most commonly prescribed anti-inflammatory drugs on the market. The member had one of six common conditions for which the drug could be consumed once every other week. However, the doctors had prescribed the drug once every week. After ELMCRx’s consulting, the frequency of drug consumption and cost of medication were brought to half of their original values and $60,000 could be saved.
Since bringing Tesser Health and its data driven platform into the organization, ELMCRx has been able to expand its programs to provide end to end cost containment solutions to employers, “From $1 to $1,000,000”, according to Dr. Ali Khoshnevis, Chief Medical Officer of Tesser Health. “Combining our analytics platform with ELMCRx’s clinical expertise, creates a very strong model to guide healthplans and consumers to better choices”. To bestow its clients with new services and tools, ELMC Rx Solutions constantly study the new formulations and drugs and their effectiveness in healthcare treatments. The company equally relies on its unique combination of technology and human expertise to overcome newerchallenges in the clinical trials that lead to drug development. The strategy will allowthe firm to remain effective and accurate in the evaluations. Undoubtedly, the firm is ready to face the new challenges in the clinical and the financial risk management arena.