Pharmacy benefit managers (PBMs) have been taking a beating in the news recently because attention is being directed to the fact that these companies are making high profits as the "middlemen" for prescription drugs (see: Reality check on PBMs and drug costs). For most patients, PBMs do not deliver any obvious service for them. I couldn't even find a web site for Caremark which is owned by CVS; you have to start at the CVS Health web page. This PBM narrative is changing because CVS knows how to impress healthcare consumers. All of this was derailed in a recent article (see: CVS Uses Analytics to Expand Transform Diabetes Care Program) with an excerpt of it below:
More than two years since its launch, pharmacy benefit manager (PBM) CVS Caremark’s Transform Diabetes Care program has helped PBM members better control their diabetes through a combination of highly personalized member support and coaching focused on improving medication adherence and better control of HbA1c. In fact, more than 50 percent of members with uncontrolled diabetes who enrolled in the program have moved to a controlled status and, on average, members have improved HbA1c by 1.2 percentage points. Building on this success, CVS Caremark is announcing an expansion of its Transform Diabetes Care program to focus on prevention and early identification of diabetes, as well as the launch of a new program, focused on hypertension, a common comorbidity of diabetes. Both use an advanced analytics engine (pharmacy, medical and lab data) to identify and enroll members who may have pre-diabetes and those who have hypertension....
As part of...[the program], eligible members will receive connected digital scale, a CDC-approved app-driven prevention program and health coaching with experts across a range of specialties (nurses, dieticians, exercise, behavioral). Members also can engage with practitioners at CVS Minute Clinics – offering a 360-degree member-centric approach to care coordination. The overall goal is to help reduce incidence of diabetes in a given population by 58 percent in three years. Given that hypertension is twice as frequent in diabetes patients, CVS Caremark will use its analytics engine to identify and intervene with members enrolled in Transform Diabetes Care who also have hypertension, through its new Transform Hypertension Care program. These members will receive a connected blood-pressure cuff, which will automatically capture blood pressure readings and store them in a secure, personal profile; an app-based hypertension management program including digital coaching, weekly challenges, and education; as well as access to specialized experts on demand for personalized condition management and support.
CVS Health now consists of (1) a huge network of retail drug stores; (2) Caremark, its PBM, which is expanding its diabetes and hypertension programs (as noted above) to include various measuring devices and app-based disease management programs; and (3) walk-in MinuteClinics that are quickly expanding to larger HealthHUBS with greater emphasis on wellness (see: CVS Health Announces Significant Expansion of HealthHUB to Deliver a Differentiated, Consumer Health Experience). All of these changes reinforce my ideas about the anticipated changes in what I have been calling first-tier of health care (see: Retail Drug Stores Emerging as Healthcare; Defining and Delineating the Changing First Tier of Healthcare).
For-profit organizations, particularly CVS Health, are going to be formidable competitors for the large, consolidating health systems in primary care (see: Get ready for a future of rampant healthcare consolidation). This is highly significant because its been estimated that PCPs in health systems are responsible for some 90% of total hospital costs (see: PCPs Responsible for Allocating About 90% of Total Hospital Costs). In the near future, CVS Health and its for-profit competitors in the first-tier space may control a large percentage of the referrals for lab testing, imaging, specialist appointments, and inpatient admissions. What's going to be their price to the health systems in exchange for such referrals?
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