St. Luke's, based in Boise, Idaho, is a not-for-profit health system that includes nine hospitals and over 300 clinics and centers for care. Recently, they launched their own employee pharmacy benefit manager (PBM) to cover 25,000 members. We spoke to Kelley Curtis, Pharm.D., MBA, St. Luke's Chief Pharmacy Officer, to learn more about this launch and other pharmacy initiatives.
Q: We know that St. Luke's recently launched an in-house PBM for its employees. How did that go? What steps did you take to prepare?
Dr. Curtis: Our launch went really well. Our HR benefit leader said that this was one of the best pharmacy benefit (PBM) transitions he's been through. We did a lot of pre-planning to make sure we had the proper resources in place. We hired a pharmacist and two pharmacy technicians, in addition to the workgroup already in place, who began work in January and February to prepare for our go-live date, April 1, 2021.
On the same day as the PBM launch, we internalized mail-order pharmacy and specialty pharmacy services for our employees. The mail-order aspect was new for us. We knew we were going to have about 300 employees that we wanted to transition over with no gaps in care. We began data and file transfers as early as possible. We were preparing for which drugs were going to be dispensed, where the shipments were going, getting licensing in place, and securing shipping supplies. Having only 300 employees utilizing mail order made it manageable.
Q: You mentioned hiring a pharmacist and a technician to help with the launch. Did you hire anyone else to help support the employee PBM?
Dr. Curtis: We hired a director, a pharmacy process control specialist who oversees the business/operations aspects, a manager who oversees the dedicated customer service line, a clinical pharmacist, and two pharmacy technicians who are focused on prior authorizations for more challenging customer service needs—and who also serve on the customer service line.
At the rate that things are going, I can see that team doubling in the next year. We also hired one pharmacist and one technician to support mail order and prepare for future growth and one technician to join the specialty medications team. We had already built up the staff there previously.
Q: What results have you seen since the launch?
Dr. Curtis: Our mail order component has grown by about 35%, just by word of mouth. We haven't advertised it, but employees are really happy with the service. We're setting a record every month for prescriptions filled.
One of our biggest successes so far has been optimizing use of pharma copay cards. We maximize the pharma copay coverage for those medications, which lowers the overall cost to the health plan. Our approach was to combine the patient journey between our specialty pharmacy team and the PBM team. This ensured our high touch model of care and help to mitigate any patient disruptions.
In the first year of the PBM, we just needed to show that we could reduce the total cost of the employee pharmacy benefit. We promised very minimal change for this first year. We've already started looking toward next year, though. We've been working with our clinical pharmacists, P&T committee, and benefits team to create a list of 10 opportunities to reduce costs and improve access to care. We're deciding together what we want to work on next.
Q: How do you manage the formulary for the PBM?
Dr. Curtis: Right now, the employee PBM has adopted the same formulary as our past PBM to minimize disruption in year one. We have a separate pharmacy and therapeutics (P&T) committee for the PBM, but we work to make sure that aligns with the system P&T.
A handful of the members, including the chairperson, are the same on both committees. This helps provide continuity. Our ultimate goal, as we take on risk for more lives with our PBM, is to have fewer formularies for our providers to manage when they're caring for patients.
As far as formulary changes, we've started reviewing newer agents, and we've made some decisions about patients starting new drugs and some drug classes. We've left people alone who have been on a drug for years. For now, we're focusing on minimal change and making note of where we can find the most savings to the health plan in the future.
Q: Thank you for the overview of your PBM work. We're excited to hear updates as you move forward and continue to grow. Have there been any other big changes in your pharmacy program recently?
Dr. Curtis: We are excited to have a dedicated pharmacy contract manager join our team. There's a gap in PBM knowledge within our health system payer team. This new role will work closely with the payer contracting department around PBM contracting.
Our team completes an annual profitability analysis of our top 40 medications. It's been helpful to have visibility into the granular detail around how much we are spending and actual reimbursement for each drug.
For example, we realized that our reimbursement was upside down on Prolia. We learned that the required documentation was a challenge for that drug. Our team took on a project to educate physicians, the clinics and build the order in Epic to improve ordering and documentation. Prolia is still not profitable, but it's closer to break even than it has been in years past.
The profitability report has also been helpful for the dedicated Medication Access Team. These are the associates who manage prior authorizations and enroll patients in medication assistance programs. We've had a lot of denials reversed because the data we gather on reimbursement brought visibility to where we were getting denials and helps the team go after them and, in many cases, reverse the denial.
Q: We'd love to get your take on where you see pharmacy heading in the next few years. What should other leaders be keeping an eye on?
Dr. Curtis: I think that it's time to implement strategies around improving medication access in our health systems. Whether it be affordability or improved access to medications that consumers expect and desire. I also believe that we need to continually evaluate our pharmacy practice model to ensure pharmacists are working at top of license and are engaged in elevating the transition of care processes, primary care expansion and post-acute care models.