PBM and Community Pharmacy Partnership Medicaid Outcomes

This technical report presents an analysis of a partnership between Elevance Health’s CarelonRx pharmacy benefit manager (PBM) and CPESN® USA, focusing on Medicaid member outcomes in Iowa. The report outlines the evolution of pharmacists' roles in managing chronic diseases and the implementation of value-based payment arrangements aimed at improving health outcomes. It details a retrospective claims study utilizing Medicaid claims data from August 2020 to December 2023, comparing outcomes for engaged members who participated in the CPESN outreach program against nonparticipant members. The results indicate that engaged members experienced a significant reduction in inpatient admissions and medical costs, alongside improved healthcare effectiveness measures, such as HEDIS gap closures. The report concludes that value-based care partnerships can enhance health outcomes and reduce costs for Medicaid members with chronic conditions, suggesting that similar models could be beneficial in other contexts.