The health care system can feel uncoordinated and costly. However, pharmacy benefit managers (PBMs) exist to fill gaps in care through innovative solutions that are responsive to member and client needs.
“As one of the only stakeholders with a connection to both payers and patients, PBMs have the unique ability to see both the financial and human impacts of chronic diseases,” said Adam Kautzner, president of Express Scripts. “Every day at Express Scripts, we use our clinical expertise and patient-centered programs to help the more than 100 million Americans we serve keep their health on track.”
PBMs boost patient adherence amid the rise of chronic conditions
Chronic conditions, such as cancer, diabetes, and heart disease, have been on the rise for more than two decades – and today, 60% of U.S. adults have at least one chronic condition. One of the biggest – and costliest – challenges in managing the rise of chronic conditions is ensuring patients get on and stay on the medicines they need.
Express Scripts is helping patients understand and manage their conditions through comprehensive disease management, including providing condition-specific coaching, tracking medication adherence, and utilizing digital tools.
Here is a by-the-numbers look at Express Scripts’ value-based patient engagement platform, according to Evernorth data:
- 27.38% higher adherence for patients with pulmonary hypertension
- An additional 17.4% of patients with diabetes who were at risk for heart attack or stroke started a statin therapy
- 63% of patients with neurological conditions who received an adherence outreach filled their prescription within 30 days
Spotlight: How Express Scripts improves outcomes for
cardiodiabesity patients
Projections show that 50% of U.S. adults will be obese by 2030, and 35.2 million U.S. adults will be diagnosed with diabetes by 2060. Both conditions are key risk factors for cardiovascular disease, which remains the No. 1 cause of death. This triple threat, called cardiodiabesity, requires a comprehensive, proactive approach to disease management.
Early stage cardiodiabesity
Advanced stage cardiodiabesity
Express Scripts provides holistic, personalized support for cardiodiabesity, including:
- A clinically proven lifestyle modification program with behavior change support designed to help participants achieve and maintain improved health outcomes.
- Digital tools, which help members taking GLP-1s adopt sustainable behavior changes for greater weight loss success.
- Relationship-based engagement opportunities, such as working closely with a care team or fellow program participants.
Over 60% of new and existing GLP-1 users enrolled in our digital solutions lost weight (%)
This approach drives better clinical outcomes for patients:
- 2.6x increase in weight loss per month and 4% average reduction in body weight for members enrolled in the digital program while using GLP-1s in 2023, according to Evernorth data.
- Increased usage of statin therapy could prevent 20,500 heart attacks over the next 10 years.
- About $35 million saved for clients and members by preventing escalation to type 2 diabetes for patients who are prediabetic and/or obese through our digital solutions in 2023, according to Evernorth data.
PBMs improve care coordination by supporting real-time decision-making
Many patients have more options than ever for when and where they get health care. However, they can also face a disconnected, siloed health care system that leads to fragmented care, which drives poorer outcomes, redundant services, and higher costs. Better benefit management can help reconcile care and costs across health practices, networks, and/or health systems so that no patients fall through the cracks.
Express Scripts supports patients by equipping physicians, pharmacies, and payers with actionable insights. “We’re improving care coordination across the health care continuum by leveraging real-time data insights to provide a 360-degree view of a patient and identifying opportunities to close care gaps,” Kautzner said.
By the numbers:
- 107% increase in medication adherence among enrolled members in 2023
- 87% of enrolled patients with diabetes took medication as prescribed in 2023
- 86% of enrolled Medicare patients took medication as prescribed in 2021
- 23% fewer hospital stays for enrolled members in 2021
- More than 353,000 clinical gaps in care were closed in 2023 for enrolled members
Source: Evernorth data/holistic clinical care program
PBMs navigate the complex specialty landscape
The specialty drug market is growing at a remarkable pace, with conditions historically treated by traditional medications now seeing more specialty approvals. As prevalence increases, so does spending. Since 2009, average per-person costs for specialty drugs have risen by $255, even as spending on traditional medications has decreased by more than $210 per person.
Express Scripts utilizes tools like drug utilization management programs to manage complex conditions and to ensure the safest, most cost-effective drug is chosen. For instance, prior authorization protocols increased guideline-recommended genomic testing from approximately 62% to 97% in 2019 in patients with advanced non-small cell lung cancer (NSCLC). Directing patients with NSCLC to the most effective first-line therapy through genomic testing resulted in improved five-year survival rates ranging from 15% to 50%.
“Engaging oncologists to conduct genomic testing before beginning treatment helps improve the cancer care experience for patients and leads to better health outcomes, which translate to lower downstream health care costs,” Kautzner said. “The savings that result from Express Scripts’ clinical expertise helps create headroom for future innovation.”
Express Scripts’ mission: Better health for all
Because PBMs like Express Scripts sit in the middle of the health care delivery system, we have the unique ability to spot and solve problems throughout the health care system to provide our clients with a successful path forward that maximizes investments in patient care and delivers improved clinical outcomes.
As the health care system evolves, list prices for medicines continue to skyrocket, and managing chronic conditions becomes more and more complex. In the face of those challenges for payers and patients, Express Scripts is positioned to use its clinical expertise, negotiating power, and tailored solutions to ensure the right drug at the right price reaches the right patient at the right time.
