Pharmacy-Insurer
Principles of
Engagement
Pharmacy and private insurers have a long history of working together to provide safe medication care to Canadians in a timely and affordable way. As highly trained, regulated health professionals, pharmacists’ top priorities are the safety of their patients and providing personalized care to each person who comes into the pharmacy. At the same time, pharmacists and their teams often act as intermediaries between insurance plans and their patients, and they are spending more time administering plans, taking them away from direct patient care.
Recognizing that pharmacy benefits make up the largest portion of extended health insurance plans, insurers and pharmacy have established a strong relationship that both plan sponsors and plan members depend on to access necessary medications to maintain a healthy population.
Specifically, plan sponsors and plan members rely on:
- Efficient, real-time adjudication through direct billing to reduce out-of-pocket costs for patients to access treatments
- Seamless communications between insurers and pharmacists to accurately and effectively administer and support the drug plan
- Pharmacists as partners in managing drug expenditure through the evaluation and selection of appropriate and cost-effective therapies
Just as pharmacy practice can impact plan member experience and improve health outcomes to the benefit of plan sponsors and insurers, insurer policies have a direct impact on pharmacy practice. Pharmacy and insurers must work closely together to ensure that patients and plan members have access to be the best possible care and a great experience at the pharmacy.
Objectives
Pharmacists’ objectives in working with insurers include:
- Fostering an environment where pharmacists can spend as much time as possible providing direct patient care, through counselling and other services to support optimal medication use
- Demystifying and facilitating drug coverage issues while delivering the highest standard of patient care
- Providing timely and quality services to promote the overall health of employees and hence a healthier workforce for employers
- Reducing administrative burden and increasing cost-savings to insurers and employers by Pay Direct Drug (PDD) claims submission
- Creating more uniform and standardized policies across insurers that are aligned with all relevant provincial and federal privacy regulations
Pharmacy Priorities
As insurers try to contain and reduce their overall costs, they are introducing and implementing programs and policies specifically directed at pharmacy practice. Increasingly, these policies are placing considerable administrative burden on pharmacists, taking them away from providing care or restricting the care available to their patients and to plan members. These can range from small processing issues to large scale reform of pharmacy practice.
While pharmacy recognizes the desire for insurers to distinguish themselves in the market, this can also cause significant challenges for the pharmacy team when submitting online claims to drug plans on behalf of the patient. This is why we believe some consistency across insurers can support pharmacy practice and ultimately benefit patients.
In order to address these objectives effectively, there are 6 key elements that have been identified as priority areas to enhance collaboration between pharmacy and insurers:
Professional autonomy
Programs should be designed to encourage pharmacy best practices that provide optimal patient outcomes at the best value. Pharmacists consider a multitude of variables prior to selecting a specific therapy for a patient. Programs must therefore allow for flexibility to ensure that pharmacists are able to exercise their professional judgement to prescribe and dispense treatments most suited to the specific clinical profile of a given patient.
Engagement
In order to effectively anticipate potential operational issues, it is critical for insurers to engage with pharmacy stakeholders in advance of implementing new policy changes. This early engagement will allow for meaningful discussions on how to possibly improve policy uptake, prevent negative member experience from benefit plan issues, as well as achieve mutually beneficial outcomes. The best way to facilitate this engagement is to invite pharmacy to stakeholder consultations and maintain ongoing communications with pharmacy.
Communication
Policy and program changes should be communicated with pharmacy stakeholders, including CPhA, provincial pharmacy associations and regulatory authorities. It is also important for insurers to communicate directly with prescribers and patients to increase understanding of the changes.
Advance Notice
Pharmacy providers and stakeholders should be given at least 6 weeks’ notice before policy changes take effect to allow for time to adjust internal procedures and to ensure there is a thorough and accurate understanding of the intent of the changes.
Remuneration
Pharmacies should receive reimbursement for activities that are performed on behalf of insurers, including compensation for the time required to make changes to prescriptions as a result of policy changes, explaining policy changes to prescribers and patients and to contacting insurers on behalf of patients.
Audit
While no pharmacy stakeholder supports fraudulent behaviour, insurers should audit in the spirit of educating pharmacists and pharmacy staff to prevent future issues and ensuring accountability and transparency of the cost recovery process which allows for billing error corrections. Audit processes should be clearly outlined and ample notice should be given to pharmacy providers to conduct an internal investigaton, take corrective action and follow-up where needed.
Download PDF — Pharmacy-Insurers Principles of Engagement
A dedication to these principles of engagement will support enhanced collaboration and increased engagement between insurers and pharmacy stakeholders, leading to more seamless patient care and improved outcomes for Canadians.