Carelon: Beyond the pharmacy. The impact of pharmacy benefit managers in fulfilling the potential of integrated care

Pharmacists are an important link to driving connection in the healthcare system. That’s why behind pharmacy benefit managers (PBMs), a countless number of pharmacists and pharmacy technicians in the industry are connecting one-on-one with patients daily to help make higher quality, integrated healthcare possible. 

One of those pharmacists is Farrah Burk, PharmD. Recently, Dr. Burk found herself talking to Martha* during a routine medication review. As Dr. Burk went through Martha’s medications, she learned that Martha was struggling with extreme stress and anxiety following the death of her mother. Scared and concerned, Martha asked Dr. Burk for help.

In that moment, Dr. Burk was able to connect Martha to Carelon’s behavioral health services case managers to ensure she received coordinated care. 

“Each day, I get to know our members personally and help them with whatever barriers they may face, which not only include medications but also helping with social and economic conditions that can affect their overall health,” Dr. Burk said.

Dr. Burk is one of approximately 400 pharmacists and pharmacy technicians on the Clinical Pharmacy Care team at CarelonRx who take the time to engage and help individuals navigate and address their medical, physical, and whole health needs around the clock. 

Medication compliance and adherence challenges – especially among individuals with chronic and complex conditions – are just one of many reasons why support from Dr. Burk and others like her is critically important. And efforts like these pay off for patients and the healthcare system alike. 

For diabetes patients alone, PBMs improve drug therapy and adherence and annually prevent:

  • 440,000 heart attacks
  • 60,000 incidents of kidney disease
  • 330,000 strokes
  • 150,000 amputations

Through their specialty pharmacy services, PBMs will also help to extend and improve upon the quality of life for patients battling complex conditions such as multiple sclerosis and rheumatoid arthritis.

In an increasingly complex healthcare environment – driven by an aging population and an increase in chronic, comorbid conditions – the need for more connected and integrated care is becoming more important. Consider that on an annual basis, nearly 4 billion prescriptions are filled in the U.S., and that the FDA receives more than 100,000 reports associated with preventable medication errors. Within the next decade, PBMs are projected to help prevent 1 billion medication errors

In addition to addressing complex challenges and delivering value through cost savings, PBMs are critical in improving medication accessibility, health equity, and outcomes.

CarelonRx, the PBM within the Carelon healthcare services brand, works to address health equity on multiple fronts, beginning with syncing our data and analytics and clinical programs. By taking this approach, we ensure members get their appropriate medications while reducing the risk of errors or negative drug interactions, as well as access to additional behavioral health services, community resources, and providers. This allows us to help close gaps in care and drive medication adherence. By focusing on whole health, affordability and connected care through a clinical-first lens, we’re committed to putting the benefits back in pharmacy. 

As we work to keep care integrated, we are investing in the health and wellbeing of those who take specialty drugs. While taken by just 2% of the patient population, specialty medications are a significant and growing cost driver, totaling $301 billion in 2021 — an increase of 43% since 2016, according to a brief by the Assistant Secretary for Planning and Evaluation, who advises the Secretary of the Department of Health and Human Services. To better meet these patients’ whole health needs, we’ve integrated end-to-end pharmacy services for consumers to deliver greater affordability and access to critical medications. These services, coupled with digital innovations enabling real-time pharmacy benefit checks and improved member experiences, are critical to reducing barriers to better health and empowering individuals.

By integrating medical, behavioral, and pharmacy benefits, using holistic clinical insights, and collaborating with a patient’s care team, PBMs like CarelonRx have the opportunity to address the many challenges patients face and connect patients with the right medicine, at the right time, at the right price – translating to higher quality outcomes without sacrificing cost. 

When the many parts of the healthcare system work together in a patient-centered way, people can have the enhanced healthcare experience they deserve.

Peter Haytaian serves as executive vice president at Elevance Health and is president of Carelon. Paul Marchetti is president of CarelonRx.

*Name changed to protect patient confidentiality

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