Pharmacy U

How well do you understand the role of private payers in pharmacy?


Oil and water: that’s often the perception of pharmacists and private payers. But that perception is actually a misconception.


By donalee Moulton



Indeed, working together with private payers, pharmacists can play a critical and expanded role by being actively involved in treatment selection.

“Pharmacists have the knowledge about drugs and their costs and can help all patients reach the best outcomes at the lowest possible cost. This, in turn, can help to preserve their drug plans well into the future,” says Dean Miller, President & CEO of Whole Health Pharmacy Partners and former Vice President of Business Development & Government Relations with Remedy’s Rx.

Understanding the role of the private payer is critical to implementing an expanded scope of practice and further helping patients. “The role of private payers has been a bit of a mystery to many frontline pharmacists,” notes Miller. “Payers have typically been seen as claims adjudicators, and causing extra work for pharmacists and patients. What frontline pharmacists may not know is that private payers are responsible for the biggest part of their business income. They have a significant impact on a pharmacy’s viability and the products and services we provide for our patients.”

Pharmacists and private payers share a common focus: the patient/employee. Patients rely on their pharmacist to help answer questions about their medications including their drug plan coverage. “Benefits are things people don’t think about until they need them. That leaves the pharmacist as an educator about coverage, but the pharmacist is often uninformed,” notes Miller.

Some private payers are looking at working with pharmacists to give them the needed tools to educate their patients about their coverage. For example, the Toronto-based Reformulary Group offers pharmacists and their patients full access to its list of preferred and non-preferred drugs as well as tools to help ensure the patient receives the most clinically-effective medication at the lowest price for both the patient and employer. They even provide tools such as a fax template through their website to facilitate physician communication to switch a prescription to a preferred drug.

“The pharmacist has a key role to play in helping Canadians get healthier,” says Reformulary president and CEO Helen Stevenson. “We work closely with the pharmacy community to provide information and options to assist them now and moving forward. For example, many pharmacists want to help their patients choose the most cost-effective option to improve their condition through their expanded scope such as adaptation and therapeutic substitution. Our formulary embraces that. By partnering together, we ensure that we maintain the plans that patients and pharmacies require.”

Professional associations are also actively working to take the mystery out of the pharmacist/private payer relationship. The Ontario Pharmacists Association, for example, devotes a section of its website to drug plans and formularies and is currently in the process of developing a private payer strategy.


The search for ROI


At present, Canadian companies spend about $280 million a week on prescription drugs. Return on investment – in the broadest sense – is an important consideration for plan sponsors. Reformulary Group has been able to show how its dynamic formulary is benefiting its clients. For instance, JOEY Restaurants, which has 3,300 employees spread across restaurants in four provinces and one U.S. state, was looking for a drug plan that encourages employees to be engaged and make informed choices about the prescription drugs they are taking.

“Engaging plan members was an important part of changing our plan,” says Andrew Martin, JOEY’s vice president of human resources, in Vancouver. “Our employees didn’t understand drug pricing. So we decided to do a Reformulary road show. We visited each restaurant to educate staff so they would understand how their preferred drug spend choices would help us all keep, or even improve, our existing coverage. It’s been smooth sailing ever since.”

Miller points out that tools such as those provided by the Reformulary Group enable pharmacists to get answers for patients about their drug coverage more quickly and effectively than ever before. “Companies are making it much easier to access resources, and this rapid access allows pharmacists to provide patients with the medication they require in the most cost-effective manner. We no longer have to reinvent the wheel and make a call every time a patient has a question about their plan.”

Still, more work is necessary, says Miller. He notes that pharmacists, for example, often opt for the clinical stream at conferences over the business stream. The latter, however, would provide more insight into working with private payers. He also recommends inviting private payers to speak at local and other pharmacy events and reaching out to them directly to build ongoing relationships.

The opportunity to find common ground is significant. “Pharmacists are quasi-drug plan managers interacting with plan members every day at the pharmacy counter. We are aware that many pharmacists have been helpful to plan members, in transitioning them to our preferred drugs, for example. We are keen to see their scope continue to expand,” notes Stevenson. “Pharmacists can help members with complex medical conditions optimally manage their medications and ensure adherence. From an employer perspective, if members are optimally managing their medications, this should translate into better patient outcomes and long-term savings.”