Aug 8, 2024
Team approach to prescription drugs and medical care
How a health plan’s key partnership is making a difference in its members’ lives
When pharmacist Sam Jentink checked up on an asthmatic child recently, he was startled to find a prescription for a rescue inhaler had been filled five times in less than 4 months.
Typically, rescue inhalers are used only when a person experiences acute symptoms, while a controller medication is taken every day to treat the underlying conditions that cause asthma. Using a rescue inhaler rather than taking a controller medication can silently damage the lungs and lead to chronic lung disease.
So Jentink called the child’s physician to make sure she was aware of the apparent over-dependence on the rescue inhaler. It turns out the doctor was not and called Jentink back.
“She told me she thought that it was probably nothing, because the parents are divorced so they are likely getting multiple inhalers to keep in their separate homes,” recalled Jentink. “But she did call the child’s caregiver just to check. It turns out the child was using their inhaler every day, multiple times a day! The provider told me she was changing treatment to ensure the child’s asthma was better controlled and just wanted to let us know that our call made a difference.”
Because the child’s family had a Blue Cross Blue Shield of Massachusetts health plan that integrated pharmacy benefits with medical benefits, they got the benefit of pharmacists working to ensure their quality of care.
Jentink and his colleague Catherine Barber have been assigned full time to Blue Cross members by CVS Caremark, which manages the not-for-profit health plan’s pharmacy benefit. The three-year Blue Cross-Caremark deal is expected to decrease the insurer’s pharmacy spend, which will benefit customers.
How a combined medical and pharmacy benefit works
The pharmacy benefit, covering prescriptions, is the most utilized benefit in health insurance. Some employers choose to “carve out” the management of their pharmacy benefit to a third party, hoping to save money. However, that can lead to a disjointed experience for the plan member as well as uncoordinated care, said Mary Beth Erwin, chief pharmacy officer for Blue Cross.
“By combining the medical and pharmacy benefit under one plan, we can offer our members and the clinicians who care for them a simplified but more aligned and transparent care experience, aiming for better health outcomes and lower costs.”
Chief Pharmacy Officer Marybeth Erwin
On the hunt for prescription drug quality issues
Jentink and Barber comb through pharmacy claims looking for prescriptions that don’t align with nationally accepted standards set by the National Committee for Quality Assurance.
When they find something off, like the recent case of the young member with asthma, they reach out to the prescribing clinician.
Other quality measures Jentink and Barber monitor include ensuring people with high cholesterol, cardiovascular disease and diabetes are taking their medication as directed.
Sometimes, Jentink or Barber will decide that a call to the provider is not enough and will contact one of Blue Cross’ in-house pharmacists to ask them to contact the member directly.
The Blue Cross team of pharmacists can reach out to help members who may not be taking their medication as directed, or who may be having trouble affording their prescription, as well as cases where the pharmacy cost is unusually high.
In one recent case, a pediatric patient was being switched from a very expensive brand version of a needed drug to a more affordable generic version. The doctor making the change informed the child’s mother. And while there was no resistance to the change from the prescriber or the family, Blue Cross pharmacist Josephine Loya reached out to ensure the mom had no concerns.
“She was very surprised and appreciative that she heard from her provider and her insurance company,” said Loya.
For all three pharmacists, this work matters.
“I do this work because I empathize with patients, I’m very aware of how important it is that they get the medicines they need at an affordable price.”
Pharmacist Catherine Barber
“Blue Cross values quality,” said Loya, “and we’re helping to ensure the quality of care.”
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