The Value of Having Practicing Providers at Medicaid Pharmacy Benefit Management Companies


The complexities of today’s healthcare market have led to the need for Medicaid pharmacy benefit management companies to keep up with new and novel treatments, manage health crises, and navigate changing regulations. Some of the most valuable resources available to assist in doing so include having practicing providers on staff to support state Medicaid agencies with their current needs as well as keep up with the ever-changing healthcare landscape. Change Healthcare’s Pharmacy Benefit Solutions provides this and much more.

By: Dr. Laureen Biczak, DO, chief medical officer of pharmacy benefit solutions at Change Healthcare

A key benefit of including physicians in the staffing of your pharmacy benefits vendor is the type of clinical knowledge they bring. Experienced pharmacists are critically important to the success of pharmacy benefit management companies (PBMs); but some types of information, such as laboratory testing or CPT and HCPCS coding, are often better understood by physicians. These can be important components to consider in setting up and managing complex drug utilization reviews (DUR) or reporting parameters.

In addition, there are areas that are better addressed by pharmacists; but the knowledge and approaches are complementary, and clients are often best served by having team members with both knowledge sets available. Peer-to-peer calls are often most successful when physician-to-physician discussions are available.

The clinical knowledge and real-world experience of practicing providers also helps Medicaid PBMs manage the complex and changing healthcare environment.

Support for new treatments and health crises

It’s challenging to keep up with current drug and medical protocols; but the frenetic pace of new and innovative medical treatments, including genetic therapies and other emerging technologies, can be overwhelming.

Practicing providers at a PBM can help. Staff physicians can evaluate new therapies and determine when and if they are necessary. As many new treatments are costly, the review and management of new therapies is critical.

In addition, new treatment requests can be complex and are often best handled physician to physician. In peer-to-peer interactions with prescribing clinicians, PBM practicing physicians help ensure that patients receive care consistent with evidence-based best practices.

Resources for new laws and regulations

When Medicaid benefits change, states and Medicaid PBM companies work together to implement those benefits.

Experienced Medicaid PBM practicing physicians can serve as a resource to clients. State medical directors and pharmacists can reach out to PBM physicians for both policy and medical input on issues, criteria, and difficult determinations.

Because our physicians work with many clients, including multiple state Medicaid programs, they can share best practices and often have a working knowledge of what is and is not working in various geographic areas.

Providing expertise and improving outcomes

Combined with our experienced team of pharmacists, we have a deep bench of clinicians who are immersed in the world of pharmacy and Medicaid pharmacy and are available to serve our current and future clients. We support evidence-based care of our client’s members or enrollees by assisting with the support and management of meaningful and impactful clinical programs aimed at improving outcomes while managing costs.

The idea of including practicing providers on staff at a PBM is a new one for many clients. Learn more about how our Medicaid Pharmacy Benefit Solutions include practicing providers that support you and your plan participants.

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