HealthJanuary 22, 2024

Drug decision-making: Why alignment between PBMs, payers, and other stakeholders matters

To keep patients and members safe without sacrificing efficiency or profit, healthcare businesses need consistent drug data to help align decision-making and communication between players including pharmacy benefit managers, payers, physicians, and pharmacies.

Aligning drug data is crucial for effective decision-making

Drug decisions are not made in a linear fashion. Rather the various players involved in the lifecycle of a prescription engage in frequent back-and-forth:

  • Pharmacy benefit managers (PBMs) / payers and physician offices/ electronic medical records (EMRs) communicate back-and-forth regarding what’s on patient’s drug formulary.
  • Physician offices/EMRs and retail pharmacies send each other requests for electronic prescriptions and refill orders.
  • Retail pharmacies and PBMs/payers are in constant contact regarding drug claim submissions and co-pay amounts.

This frequent exchange of data presents many opportunities for miscommunications and incomplete or inconsistent transfers of information. When these partners can align their drug decision workflow with a consistent drug data solution, it can help streamline processes and unify decision-making and communication across the continuum of care.

Drug data efficiency at the business level for prescribers, PBMs, and payers

Aligned data allows prescribers to choose the most cost-effective and time-effective scenario for their patients from the start by selecting only those drug therapies that are approved and on the payer’s formulary.

Payers perform analytics on drug products and drug pricing in part as a form of checks and balances on their PBM partners. When both PBM and payer are using aligned data associated with National Drug Code (NDC) identifiers that understand each other and can communicate information with interoperability to common pricing points, communications and business processes are more likely to proceed smoothly.

Clinical consistency across the healthcare ecosystem

The PBM, prescriber, and pharmacy are all likely to perform a clinical screening to check a new prescription for drug interactions based on available information about the drug product and the patient or member’s current profile. 

The more synchronized the physician and pharmacist’s interaction screening results, the fewer questions might arise. It stops a work-and-care-delaying phone call between those two players, especially if it's a severe enough interaction that might spark one or the other to suggest a change in therapy. Overall, these more efficient and aligned interactions are likely to enhance patient safety reducing the likelihood of medication errors.

Pricing data consistency impacts drug decisions

Drug pricing data resources matter, as there is no single drug price benchmark to determine coverage and reimbursement.

However, it can be difficult for two businesses using disparate data sources to determine why their prices may not be aligned – is it because the two businesses are using entirely different pricing concepts, or are they using the same pricing concept but formulated differently by two vendors with varying editorial policies?

Using aligned resources with consistent editorial policies for pricing data reduces the need for manual interventions, questions back to the vendor, and process slowdowns that could impact resourcing availability.

Learn more: Download our drug management and decision-making eBook

When partner healthcare businesses are communicating using aligned drug data solutions it creates confidence and security in decision-making while benefiting patient and member safety and trust. To learn more, download the eBook, Aligning data resources to drive drug management and decision-making.

Download the ebook by filling out the form below.
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