Dr. Alison Lum explains why fixing a complex ecosystem is possible but requires all stakeholders.
Devouring an elephant one bite at a time happens faster at scale.
One of healthcare's elephants is prescription drug cost, effectiveness, and patient experience. Scale is achieved when commercial market players target these challenges systemically.
Blue Shield of California's Health Reimagined is an example. The initiative is taking a bite out of healthcare dysfunction by executing strategies at specific points of the ecosystem. This includes the plan's prescription drug programs with Civica Rx, Evio Pharmacy Solutions, and Gemini Health.
HealthLeaders spoke with Dr. Alison Lum, Blue Shield's VP of pharmacy services, and asked her about the brave new world that sees health plans involved in prescription drug manufacturing.
"That resonates with me," she says, detailing Blue Shield's efforts and how her love of chemistry and community pharmacy called her to make a bigger difference.
"It all ties back to being dedicated to a mission worthy of our family and friends. We can't do this on our own. It has to be holistic across the ecosystem—not just pharmacy—while also getting back to simplicity."
In 2020, Blue Shield launched Health Reimagined to focus on whole-person care for its 4.4 million members and on systemic change for California. Initiatives address holistic health, high-tech and high-touch support, and personal care. A sample of program results through June 2021 included:
- Community health advocates: Advocates helped segment the highest-priority social service needs across multiple regions—from transportation (21% in Butte County) to mental and behavioral health (21% and 25%, respectively) in Sacramento and Los Angeles counties, with added food assistance needs identified in L.A.
- Real-time claims: Initiative expanded from a two-hospital system to a 20-hospital, statewide initiative.
- Primary Care Reimagined: More than 100 physician groups gained access to tech resources that support care delivery, value-based care (VBC), and predictable revenue.
Prescription drugs are part of these efforts, given their role as cost driver and the complexity of what Lum calls the "prescription drug ecosystem." Detailing the path—from wholesalers, distributers, and pharmacies to providers, plans, pharmacy benefit managers, and patients—Lum emphasizes: "And this is the simple version."
She adds that while plans never touch a drug, they touch the dollars: "We won't be able to address unless every single stakeholder makes a change. Where we are part of the problem, we need to fix it."
Ecosystem inflection 1: manufacturing
How do you lower the cost of insulin? Make it yourself.
In March 2022, Blue Shield joined Civica Rx's effort to manufacture and distribute generic insulin at a well-below-market price of $30. According to a press release, "Blue Shield is a founding investor of CivicaScript … Civica's operating unit dedicated to lowering the cost of select high-cost generic medicines at the pharmacy counter."
In that release, Blue Shield president and CEO Paul Markovich adds that the collaboration "is an investment in public health in our state"—supporting the plan's commitment to systemic transformation through initiatives like Health Reimagined.
Lum tells HealthLeaders that Civica Rx is an example of "a generic manufacturer looking to disrupt the marketplace—trying to figure out how to ensure that there is a price, that it is transparent, and that [plans and patients] know exactly what we're paying for it."
Ecosystem inflection 2: from evidence to experience
If you can't help make a drug, prioritize the ones that are the most effective.
Blue Shield's investment in Evio Pharmacy Solutions targets data-driven prescribing decisions that help lower cost while improving experience across stakeholders. A Blue Shield press release states that Evio's purpose is "to create value for its investor health plans and the members they serve by improving medication affordability, patient experience, and clinical outcomes" via:
- Analytics on real-world drug performance and patient experience.
- Scaling and integrating findings across health plans.
- Aggregating data and insights to advance VBC, including alternative payment contracts for expansive drugs.
Evio—which is "reimagining pharmacy to help ensure the right medications get to every patient, where, when and how they need it"—includes four other health plans investors: Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of Michigan, Highmark, and Independence Blue Cross.
Ecosystem inflection 3: point of care
Why prescribe a drug a patient can't afford?
Blue Shield's partnership with Gemini Health provides prescription drug information at point of care. The plan reports that since its 2019 launch, the program has saved more than $20 million, has grown to nearly 80,000 health system and medical group providers, and has identified lower-cost alternatives for 40% of patient drugs.
"A big part of someone's experience is how much they have to pay," says Lum. "That impacts their livelihood." In a press release, Lum announced that Blue Shield was expanding the Gemini Health initiative "to include pharmacists and other health care providers in our network as we reimagine how health care is delivered for all Californians."
From chemistry to systemic change
"Most pharmacists get into healthcare because they love chemistry," says Lum,: "I have worked in community pharmacy, helping my neighbors take care of themselves. I didn't want to continue to do that one person at a time."
Lum notes that she is now "thrilled to be working with an organization that is a leader in the state and nation." Noting the role that all stakeholders play to improve healthcare, Lum adds: "I hope we get to a tipping point—that we can inundate with new approaches that span all drugs and ways of paying for value to create sustainability across the system."
“We won't be able to address unless every single stakeholder makes a change. Where we are part of the problem, we need to fix it.”
Alison Lum, vice president, pharmacy services, Blue Shield of California
Laura Beerman is a contributing writer for HealthLeaders.
Blue Shield of California's pharmacy strategy includes three partnerships that target manufacturing, evidence, patient experience, and point of care.
These strategies are part of the plan's Health Reimagined initiative.
VP of pharmacy Alison Lum details these programs and her path from community pharmacy to creating state and national impact.