An integrated medical and pharmacy management company will have much broader, timely access to members’ health information, creating a wealth of opportunities.

This blog was originally posted on OliverWyman.com

A healthcare fairy tale.

Once upon a time, there was a woman named Rachel, a 67-year-old Medicare Advantage member. Rachel stops by her corner retail pharmacy one day to purchase cleaning supplies. She decides to get her flu shot while there. Seems like a normal enough story, right? Well…this is where the fairy tale begins:

Imagine the pharmacist administering Rachel’s shot pulls up her medical file and immediately receives an automatic message, which reads:

  • Rachel is overdue for a wellness visit.
  • Rachel last picked up her monthly insulin prescription five weeks ago.
  • Rachel needs lab work.

Using this information as a guide, the pharmacist immediately schedules Rachel’s wellness visit, counsels her on medication adherence, and directs her to an onsite retail clinic. Rachel’s worrisome HbA1c results go straight to both her health insurance company and primary care physician. This triggers outreach from a health navigator, who learns Rachel is struggling to pay for her medication, switching her to a no-copay prescription.

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Many patients like Rachel don’t have the same happy ending

A story like Rachel’s where healthcare is seamless, quick, and personalized is rare to non-existent. The more likely, real ending of our story? Rachel probably does not receive such high-quality attention to detail, ultimately being overlooked. Following her flu shot, Rachel experiences a gradual loss of control over her diabetes, followed by early stages of diabetic neuropathy.

Here’s more on healthcare’s reality. According to our recent consumer survey:

  • Nearly 30% of individuals experienced frustration getting care in a timely and convenient way over the past year
  • Nearly half are looking for support in managing their own health in areas like diet and exercise
  • Over 25% of consumers say they’d pay to have more coordinated, comprehensive access to their health records
  • Nearly a quarter would pay for a healthcare guide

How to rewrite healthcare’s story

Various mergers between health plans, pharmacies, pharmacy benefit managers, and retail organizations recently achieved significant milestones, and have potential to make Rachel’s “fantasy” commonplace reality. For example:

  • United Healthcare has taken a bold step into mental health by acquiring Genoa Healthcare, who runs pharmacies inside mental-health centers and offers tele-psych services.
  • The insure / PBM mergers, CVS/Aetna, and Cigna/Express Scripts have been completed.
  • A recently announced Humana and Walgreens collaboration envisioned a deeper integration of services: they will adopt a senior-focused neighborhood approach to health that brings together primary care, pharmacy, in-person health plan support, and other services for Medicare beneficiaries.
  • Cigna and CVS launched Cigna Health Works. The program combines capabilities of health plan analytics, retail pharmacy / clinic and mail order pharmacy to provide commercial members with an integrated experience.

Identifying tomorrow’s 0pportunities

These moves all represent an opportunity to create an integrated member health management and to merge the traditionally sequestered areas of medical and pharmaceutical care and management. An integrated medical and pharmacy management company will have much broader, timely access to members’ health information, creating a wealth of opportunities.

Pharmacy operators (such as retail, mail, and specialty) will have a richer member profile beyond the simple member eligibility files health plans send. This information could fuel more integrated clinical interventions. For instance, having a full list of medical events could help them conduct health education at point of pharmacy sale. This could also support improved consumer experience and engagement as better information around members’ engagement preferences helps them customize communication approaches to improve medication adherence.

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On the other hand, health plans will have the opportunity to leverage retail and pharmacy interactions as full-fledged member touch points to support overall better management.

For example:

  • A member’s over-the-counter purchase could inform a missed diagnosis
  • Pharmacies could be charged with completing Medication Therapy Management or Mediation Reconciliation at point of sale for eligible members
  • New expectations and requirements to better integrate pharmacy and medical management will require significant effort from health plans.

This new chapter of healthcare is up to us to write.

Tomas Mikuckis is partner, health and life sciences, Oliver Wyman; John Rudoy is principal, Oliver Wyman and Zhe Yu is senior consultant, health and life sciences, Oliver Wyman.

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