Furthermore, 36% of adults in the United States have low health literacy, costing the U.S. economy up to $236 billion every year. Americans clearly feel outmatched by the healthcare system, and there’s no surprise that costs continue to rise because of how complicated it is to navigate.
In an outdated industry riddled with problems, the stage has been set for care navigation to become an “essential” benefit provided by employers. Navigation solutions optimize healthcare spending by driving employees to the highest-quality providers in their network and supporting them through the care decision process.
Historically, navigation has stopped short of guiding consumers through the world of pharmacy benefits, the most recurring segment of healthcare and a key part of the care journey. So where do members go when they have a drug question or need help obtaining a prescribed specialty medication? The answer involves a third-party entity called a pharmacy benefits manager, or PBM, who controls the pharmacy landscape. Legacy PBMs are notorious for being inflexible and extremely hard to navigate, causing further confusion and superfluous costs.
Total drug spending is projected to grow from about $500 billion to $863 billion in 2028, and legacy players have little incentive to curb these rising costs. As drug manufacturers increase prices, PBMs push higher-rebate drugs to consumers over lower cost options with smaller rebates, raising costs for everyone. The industry needs a new model that puts the consumer at the center of care and lowers healthcare spend. Navigation is key to transforming the pharmacy benefit experience. Here’s why:
Creates a one-stop shop for all things pharmacy. 66% of all adults in the United States use prescription drugs, but might not have anywhere to turn when they have a question related to their medication. Employees who use care navigation provided by their employers are forced to look elsewhere for pharmacy benefit answers. When a consumer has to jump through multiple tools or make calls to their PBM, pharmacy, or insurer to get a resolution, it creates a huge gap in care and a poor member experience. By making navigation a component part of PBM, it allows coordination of care to be streamlined, enabling members to receive quick and timely pharmacy benefit information all in one place.
Improves health outcomes for employees. Bringing navigation to pharmacy benefits gives consumers a 1:1 relationship with a personalized, clinical pharmacist and care team who use clinical evidence and treatment guidelines to identify members who may benefit from additional therapy (e.g., prescribing statins to a diabetic if there are cardiovascular disease risk factors present), ultimately leading to greater health outcomes. Pharmacists proactively reach out to physicians to obtain a prior authorization, coordinate specialty medications, and enroll employees in patient assistance programs. If a member has a chronic condition like diabetes, pharmacy navigation guides them to the highest-quality drug at the lowest price they can afford, making sure they adhere to their treatment program. Additionally, members are prompted to do clinical assessments related to specialty medications to discuss side effects and dosing.
Streamlines pharmacy benefits administration for HR teams. Education and training for employees on their healthcare benefits is typically provided by the employer. Unfortunately, pharmacy information is usually relayed from the PBM or carrier, making HR teams the “middleman” in a convoluted game of telephone. Self-funded employers are obligated to deal with employee pharmacy benefit questions (or they route them to the carrier if fully-insured), adding an additional layer of complexity. Bringing navigation into pharmacy simplifies benefits administration for HR teams by allowing clinical pharmacists to discuss various medication options with members that apply to their specific benefit design. Pharmacy navigation helps employees identify the best drug therapy while taking the entire education and approval process off of the HR team’s plate.
Employers are expected to keep their members happy and healthy while decreasing healthcare spending, and this starts with improving their healthcare experience. Here’s the good news: Rightway is doing just that. Founded as a care navigation solution, we’ve demonstrated our ability to put the consumer first and deliver a meaningful reduction in spend. But given employer reliance on legacy PBMs, we were unable to influence pharmacy costs. That is why we decided to build a PBM from the ground up, to deliver our model at scale.
By incorporating navigation into the pharmacy benefits experience, we have reimagined the role PBM plays in healthcare. It's the only solution that empowers members with personalized pharmacist navigation, clinical management, best-in-class technology—guiding them to optimal medication regimens and savings opportunities. We believe navigation that spans across both medical and pharmacy is the industry’s best opportunity to lower costs and transform a broken system from the inside out.
Written by Jessica Williams, VP of Sales at Rightway.