Industry Consolidation Within Clinical Pathways

11/27/17
Issue
Citation

Journal of Clinical Pathways. 2017;3(9):38-39.

Affiliation

W-Squared Group, Longboat Key, FL.

Correspondence

Winston Wong, PharmD

W-Squared Group

1975 Gulf of Mexico Drive #211

Longboat Key, FL

Phone: (941) 487-7823

E-mail: w2sqgroup@gmail.com

Disclosures

The author reports no relevant financial relationships.

Key Words

Abstract: Express Scripts recently announced the purchase of eviCore, a leading medical benefits management firm, for $3.6 billion. The merger has the potential to be the first comprehensive care management offering. It cannot happen too soon. But what will the joining of these two powerhouses entail? And is the combination even viable? The greatest potential would be for the two companies to come together, coalesce into a comprehensive integrated program, and focus their efforts on future care models. The triad of efficacy, tolerability, and cost—in that order—should still be the driving philosophy. This is a situation with limitless potential. The ability to think outside of the box will determine success.


For many years, the integration of medical practice and pharmacy care was a goal strived for by many. However, it was rarely achieved. From the payer perspective, medical management meant case management and precertification. Pharmacy management pretty much focused on formulary management, step therapy, and prior authorization.  

A few plans ventured into the realm of integrated care management through the shifting of a few high-cost medications from medical side of the aisle to pharmacy management.1 That shift resulted in merely placing the provider-administered medications under tighter pharmacy management processes. Possibly the first and only example of an integrated strategy in the immunologic space was the implementation of a “self-administered injectable first” program in certain plans. In this program, patients were required to at least attempt to self-inject an immunologic biologic medication prior to receiving treatment via infusion.2 Although the pharmacy area managed this specific portion of care, it was far from what one would call integrated care. One of the major barriers cited to integrated care is that a significant portion of the insured population had their pharmacy benefit carved out separately, hence disconnecting the pharmacy benefit from the medical benefit—despite data suggesting that the integration of these areas may produce better, more affordable care.3

The disconnection between medical care and prescription utilization carries over to the provider practice. Physicians are mainly focused on medical management, with rare forays into medication management. In many situations, a treatment option decision is limited to the therapeutic class; the decision of the specific medication falls to the prescription benefit administrator. At best, we have an industry of fragmented care that is supported by vendors and administrators focusing just on their individual spheres of medical management or pharmacy benefit.

This leads to the significance of the Express Scripts (ESI) acquisition of eviCore.4 In this case, two powerhouses—ESI in pharmacy benefit and eviCore in medical management—will merge, and this combination has the potential to be the first comprehensive care management offering. It cannot happen too soon. 

The pendulum of health care is swinging from a fragmented fee-for-service environment to an accountable comprehensive care environment, with financial incentives in place for positive outcomes and cost control.5 We are seeing community practices coalesced into integrated delivery systems or accountable care organizations, with the goal of providing effective total comprehensive health care services. Such organizations usually know how to manage their patients medically, but may fall short on the medication aspect. Although medication utilization is not directly reflected in the various outcome-based performance measures, the effort to achieve acceptable scores falls short of realizing that medication utilization directly impacts the clinical outcomes being measured. As a potential supporter of comprehensive care management, the ESI/eviCore combination is an ideal solution to assist the ability of alternative care models to succeed. In some respects, this represents a combination of the future, and is beyond the reach of the contemporary traditional care models.

But one question remains: Is the combination viable? There is no question of the effectiveness of ESI to support the prescription benefit. There is no question of the effectiveness of eviCore’s ability to provide support for the medical benefit, most noted in the areas of cardiology, radiology, and oncology management. eviCore has made major inroads in the area of oncology management through their pathways program at UnitedHealthCare.6 What remains to be seen is whether hidden agendas exist that could be barriers to this merger’s success. 

We are told that eviCore will be allowed to continue as an independent company. However, one has to think that ESI is looking to use eviCore as an experiment in entering the payers’ world, where eviCore is supporting the medical management efforts. Perhaps ESI is looking to eviCore’s pathways to leverage rebate negotiations? Either is possible, but the greatest potential would be for the two companies to come together, coalesce into a comprehensive integrated program, and focus their efforts on future care models. For eviCore, there is an opportunity for pathway programs to become more defined, with the previous core program being anchored by the National Comprehensive Cancer Network guidelines.7 The triad of efficacy, tolerability, and cost—in that order—should still be the driving philosophy. This is a situation with limitless potential. The ability to think outside of the box will determine success.

References

1. Einodshofer MT, Duren LN. Cost management through care management, part 2: The importance of managing specialty drug utilization in the medical benefit. Am Health Drug Benefits. 2012;5(6):359-364.

2. Strootman V, Gregory C. Self-administration of intravenous medications. Specialty Pharmacy Times. December 13, 2013. https://www.specialtypharmacytimes.com/publications/specialty-pharmacy-times/2013/nov_dec-2013/self-administration-of-intravenous-medications. Accessed November 6, 2017.

3. Walker T. Integrating pharmacy benefit, medical benefit cuts costs. Managed Healthcare Executive. November 29, 2016. http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/integrating-pharmacy-benefit-medical-benefit-cuts-costs. Accessed November 6, 2017.

4. Bomey N. Express Scripts buys medical benefits management firm eviCore for $3.6 billion. USA Today. October 10, 2017. https://www.usatoday.com/story/money/
2017/10/10/express-scripts-evicore-acquisition/749382001/
. Accessed November 6, 2017.

5. Fernandopulle R. Breaking the fee-for-service addiction: Let’s move to a comprehensive primary care payment model. Health Affairs. August 17, 2015. http://www.health
affairs.org/do/10.1377/hblog20150817.049985/full/
. Accessed November 6, 2017.

6. Expansion of prior authorizations. eviCore website. https://www.carecorenational.com/news/expansion-of-prior-auth-protocols.aspx. Accessed November 6, 2017.

7. About the NCCN clinical practice guidelines in oncology. National Comprehensive Cancer Network website. https://www.nccn.org/professionals/. Accessed November 6, 2017.